**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined the facility failed to assist one of one (Resident 43) residents in making transportation arrangements to and from multiple orthopedic surgery appointments resulting in actual harm by causing a deterioration of the wound and being admitted to a hospital for wound washing, and failure to follow a medication order from the physician for one out 19 residents reviewed (Resident 30). Findings include: Review of Resident 43's admission Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs), dated November 29, 2024, revealed the resident was admitted on [DATE], was understood, could understand others, was cognitively intact, dependent on staff for care needs, and had a fracture of lower end of right femur (thigh bone), fracture of T9-T10 vertebra (spinal cord), fracture of ribs, fracture of lower end of left radius (forearm), displaced [NAME] fracture of left tibia (lower leg), other fracture of upper and lower end of left fibula (calf bone), displaced bicondylar fracture with nonunion (knee joint), and displaced bicondylar fracture of right tibia. Review of Resident 43's physician follow-up note dated January 10, 2025, at 2:33 p.m. revealed Resident 43 was evaluated due to nursing concerns over worsening right lower extremity (RLE) wound. Further review of the follow-up note revealed Resident 43 was not able to attend (his/her) orthopedic surgery appointment on January 6, 2025, due to not being able to cover the out-of-pocket expense. Review of wound care progress note dated January 10, 2024, revealed Patient has follow-up appointment with surgeon on January 13 regarding worsening right leg surgical repair, Transportation scheduled, and payment has been confirmed by husband. Nurse Practitioner (NP) aware of same. Review of Resident 43's physician follow-up note dated January 13, 2024, revealed Resident 43 was seen for a worsening right lower extremity (RLE) wound and concern for missed orthopedic surgery appointments and an order for Bactrim [double strength] tablet 800-160 milligrams, give 1 tablet by mouth every 12 hours for bacterial infection/worsening leg wound for 7 days and oxycodone [hydrochloride] oral tablet 5 milligrams, give one tablet by mouth every 4 hours as needed for moderate to severe pain. Further review revealed [Resident 43] wished the facility worked with a different service and was also upset that (he/she) was having to do follow ups and schedule them (him/herself). Interview conducted with Resident 43 on January 13, 2024, at 10:02 a.m. reported that (he/she) has missed multiple orthopedic surgery appointments (January 13, 2025, and January 6, 2025) due to not being able to cover the out-of-pocket expense to use [medical transportation services]. Resident 43 reported [medical transportation service] is the only transportation service the facility uses. Resident 43 reported each use of [medical transportation service] cost's a minimum of $1,300. Subsequent interview with Resident 43 revealed resident is worried that (he/she) will miss additional orthopedic surgery appointments due to not being able to cover the cost. Resident 43 also reported the pain from her right lower extremity wound is intensifying, requiring staff to administer her oxycodone pain medication. Review of Resident 43's clinical record revealed a progress note dated January 15, 2025, at 5:30 p.m. indicating Per NP, patient's surgeon requesting patient be sent to [Hospital] for washout of RLE surgical wound. [Medical transportation company] transport arranged and patient left facility via ambulance. Husband and daughter updated. Interview with the Social Worker, Employee E13 on January 16, 2025, at 11:55 a.m. revealed, (he/she) was aware Resident 43 had missed multiple appointments due to the inability to cover the out-of-pocket expenses. Social Worker, Employee E13 acknowledged, (he/she) had not attempted to arrange alternative transportation options or provided Resident 43 with resources to secure (his/her) own transportation. Interview with the Director of Nursing (DON) on January 16, 2025, at 1:15 p.m. revealed the facility did not follow up with [medical transport company] to determine why Resident 43 was not transported to her orthopedic surgery appointment on January 13, 2025. A follow-up interview with the Director of Nursing (DON) on January 16, 2025, at 1:59 p.m. revealed she had contacted [medical transport company] to inquire why Resident 43 was not transported to medical appointment. The DON reported the [medical transport company] did not provide transportation due to Resident 43 inability to cover the out-of-pocket expense. She further stated that she was unaware Resident 43 could not cover this expense and that the facility will attempt to schedule virtual appointments with the resident's orthopedic surgeon in the future. The Director of Nursing (DON) confirmed the previous statements and acknowledged the facility should have assisted Resident 43 in arranging alternative transportation to resident's orthopedic surgeon appointments. The DON reported Resident 43 was admitted to the Hospital for wound treatment and did not know when Resident 43 would be returning to the facility and did not have access to Resident 43's hospital records. The facility failed to ensure Resident 43 attended the orthopedic surgical follow-up appointments by not providing alternative modes of transportation or scheduling virtual appointments causing actual harm to Resident 43 when the surgical wound deteriorated and Resident 43 needed to be hospitalized for care to the worsening wound. Review of Resident 30's diagnosis list includes Acute Respiratory Failure (life-threatening condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low blood oxygen levels) and a history of Pulmonary Embolism (blood clot that blocks and stops blood flow to an artery in the lung). Review of Resident 30's physician order dated December 17, 2024, revealed an order for Enoxaparin Sodium Injection 80 mg/0.8 ml. Inject 0.8 ml (milliliter) subcutaneously (shot given into the fatty layer of tissue beneath the skin) every 12 hours for DVT (Deep Vein Thrombosis- clot in the deep vein). The medication was ordered to be administered at 9:00 a.m., and 9:00 p.m. Review of Resident 30's January 2025, Medication Administration Record revealed from January 7, 2025, until January 15, 2025, Resident 30 was not administered the medication on the following dates and times: January 7, 2025, at 9:00 a.m., January 8, 2025, at 9:00 p.m., January 9, 2025, at 9:00 a.m., and 9:00 p.m. Review of the nursing progress notes dated January 7, 2025, at 12:36 a.m., revealed medication on order, NP aware. Review of Resident 30's nursing progress notes dated January 8, 2025, at 8:29 p.m., and January 9, 2025, at 8:20 p.m., each note revealed medication was on order with the pharmacy. Review of Resident 30's clinical records failed to reveal the physician was notified of the missed medications on the evening of January 8, 2025, and the morning and evening dose on January 9, 2025. Review of the pharmacy documentation revealed Enoxaparin medication was available in the facility for emergency use. An interview with the Director of Nursing conducted on January 16, 2024, at 10:00 a.m., failed to provide an explanation why the medication was not administered to the resident despite being available in the facility. The facility failed to ensure Resident 30's physician's medication order was followed. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 8/22/24, 4/25/24, 3/15/24, 12/19/23, 5/18/23 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 8/22/24, 4/25/24, 3/15/24, 1/27/24, 12/19/23, 11/1/23, 5/18/23 28 Pa. Code 211.5(f) Clinical records Previously cited 8/22/24, 6/10/24, 4/25/24, 3/15/24, 1/27/24, 5/18/23 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing service Previously cited 8/22/24, 6/10/24, 4/25/24, 3/15/24, 1/27/24, 12/19/23, 11/1/23, 5/18/23

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, hospital records, and interviews with resident and staff, it was determined that the facility failed to provide adequate supervision and assistance, resulting in harm from a fall which led to hospitalization and further surgical procedures and treatments for one of the 19 residents reviewed (Resident 20). Findings include: Clinical records review revealed Resident 20 was admitted to the facility on [DATE], with a diagnosis of post-right below knee amputation, Osteomyelitis (bone infection), and left trans metatarsal (foot bone) amputation. Review of Resident 20's admission Minimum Data Set (MDS-standardized assessment tool that measures health status in long-term care residents) dated October 21, 2024, revealed the resident was cognitively intact. The same MDS assessment revealed that the resident required partial/moderate assistance with toilet transfers. Review of Resident 20's care plan developed on October 18, 2024, revealed an ADL (activities of daily living) care plan for the resident requiring assistance/dependent for ADL care with bathing, grooming, dressing, bed mobility, transfer, and toileting. An intervention initiated on October 18, 2024, revealed: Provide two persons assist with toilet transfer and toileting hygiene. Review of the nursing progress notes dated October 21, 2024, at 5:23 p.m., revealed Resident 20 was sent to the hospital post-fall. The same note revealed Resident 20 was transferring over to the toilet with the NA (nurse assistant) when he/she fell and hit the right leg causing surgical incision to open. The same note revealed There was a copious amount of bleeding, a pressure dressing applied, and then sent to the hospital for evaluation. Review of the physician's progress notes dated October 21, 2024, revealed resident was seen for an acute visit regarding a witnessed fall reported with an NA. The same note revealed the Resident stated that he/she was still having a hard time coping with the new right BKA (Below Knee Amputation) and did attempt to use the right leg with the transfer, causing him/her to land on his/her new BKA incision. The right BKA incision split open with profuse bright red blood present and actively bleeding. Pressure dressing was applied immediately and they advised nursing to send the resident to the emergency room for evaluation and repair of the open incision. Review of the hospital record section titled, History and Physical, dated October 21, 2024, revealed patient with post-BKA on October 15, 2024, was sent back to the ED (Emergency Department) after sustaining a fall during transfer from the commode, resulting in right BKA stump injury. The same note revealed, usually he/she has two staff members helping him/her but today it was only one. The BKA surgical site was reported to be open and bleeding at the rehab. The diagnosis was right BKA wound dehiscence with bleeding secondary to mechanical trauma. Review of Resident 20's hospital records, including Details of Hospital Stay dated October 29, 2024, revealed the patient was admitted and vascular surgery was consulted. The patient was sent to the OR (operating room) for BKA washout and wound vac (wound treatment that uses suction to help wounds heal) placement on October 23, 2024. Post-op, the patient had to be transfused with 1 unit of PRBC (pack red blood cell) due to a drop of the Hgb. He/she experienced acute urinary retention postoperatively requiring multiple straight catheters (A procedure that uses a flexible tube to drain urine from the bladder). The patient developed bleeding from the wound vac so he/she was given another unit of PRBC. Interview conducted with Resident 20 on January 13, 2025, at 10:30 a.m., revealed a few days after he/she was admitted to the facility, a male staff assisted him/her from the wheelchair to the toilet commode. Resident 20 reported it was always two people assisting with transfers but at that moment there was only one. The resident stated He/she thought he/she could handle me by him/herself. The resident further reported he/she lost balance during the transfer and fell hitting the right knee. Interview with the Director of Nursing (DON) conducted on January 15, 2025, at 1:00 p.m., confirmed there was only one person that transferred the resident during the fall. The facility failed to provide Resident 20 with adequate supervision and assistance during toilet transfers resulting in harm from falling including hospitalization, and undergoing additional surgical treatment complications post-surgical procedure. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 8/22/24, 4/25/24, 3/15/24, 12/19/23, 5/18/23 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 8/22/24, 4/25/24, 3/15/24, 1/27/24, 12/19/23, 11/1/23, 5/18/23 28 Pa. Code 211.5(f) Clinical records Previously cited 8/22/24, 6/10/24, 4/25/24, 3/15/24, 1/27/24, 5/18/23 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing service Previously cited 8/22/24, 6/10/24, 4/25/24, 3/15/24, 1/27/24, 12/19/23, 11/1/23, 5/18/23

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy and procedure review, staff interview and resident record review it was determined the facility failed to complete skin assessments to monitor skin conditions and prevent pressure ulcers for one of six residents reviewed causing actual harm to Resident 1 when they developed a stage 3 pressure ulcer to the sacrum(Resident 1). Findings Include: Review of facility policy and procedure titled Skin Integrity and Wound Management revealed under practice standards the following Complete risk evaluation on admission/readmission, weekly for the first month, quarterly, and with significant change in condition. Identify patient's skin integrity status and need or prevention or treatment interventions through review of all appropriate assessment information. Review of Resident 1's face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses of a fracture of unspecified part of neck of left femur, Lewy Bodies Dementia (affects chemicals in the brain whose changes, in turn, can lead to problems with thinking, movement, behavior, and mood), and Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Review of Resident 1's admission Minimum Data Set (MDS-periodic assessment of resident needs) dated May 9, 2024, revealed the resident was at risk for developing a pressure ulcer. Review of Resident 1's admission Braden Assessment completed on May 10, 2024, revealed the resident was at high risk for developing pressure ulcers. Review of Resident 1's baseline care plan on admission, dated May 10, 2024, revealed there was a care plan for the risk of developing pressure ulcers with an intervention of observe skin conditions with ADL care daily; report abnormalities with a date initiated of May 10, 2024. Review of Resident 1's clinical record revealed skin assessments were not completed from May 11, 2024, until June 6, 2024. Further review of the clinical record failed to reveal any progress notes of skin assessments being completed or the development of a stage 3 pressure ulcer (wound that has progressed to the third stage have broken completely through the top two layers of the skin and into the fatty tissue below). Review of Resident 1's Initial Wound Care Consult Note completed by the wound specialist, dated June 12, 2024, revealed Resident 1 had developed two DTIs (Deep Tissue Injury- localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) and one stage 3 pressure ulcer of sacral region (bottom of the spine). Interview conducted with the Wound Specialist on August 19, 2024, at 2:05 p.m. stated the facility had not completed multiple skin assessments on Resident 1 which led to the resident developing an avoidable stage 3 pressure ulcer on her sacral. Interview conducted with the Director of Nursing on August 19, 2024, at 2:15 p.m. confirmed the above information. The facility failed to monitor Resident 1's skin resulting in Resident 1 developing a stage 3 pressure ulcer to her sacral. 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 211.10(d) Resident Care Policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing service

Based on review of facility policy, clinical record, and facility documentation, it was determined that the facility failed to timely assess, monitor, and treat for suspected laundry detergent poisoning of Resident 222, resulting in actual harm of vomiting and diarrhea with a subsequent hospitalization to the Intensive Care Unit (ICU) for one of 22 residents reviewed. Findings include: Review of facility policy, Poisoning, effective December 1, 2006, revealed: Upon discovery of suspected poisoning, call for help and instruct staff to call 911. Review of Resident 222's clinical record revealed a diagnosis of Dementia (loss of cognitive functioning that interferes with daily life and activities) with behavioral disturbances. Review of Resident 222's July 2023 admission MDS (Minimum Data Set - periodic assessment of resident care needs) revealed a BIMS (Brief Interview of Mental Status) was unable to be completed due to the resident's cognitive impairment. Review of Resident 222's nursing progress notes revealed a nursing note from Licensed Nurse Employee 12 dated November 17, 2023, at 1:44 a.m., indicating: Previous nurse [(Licensed Nurse Employee 11)] reported that resident was found with laundry pods around 1530 [(3:30 p.m.)] opened in his room. Nurse reported he seemed fine. About 2030 [(8:30 p.m.)] an aide needed assistance with incontinent care for resident. When I entered the room, resident was sitting on [the bed] with vomit and feces noted around him. Resident was alert. Resident was given a shower assessed and vitals were taken. Resident was able to follow commands during assessment. On call was contacted and spoke with [provider] who gave order to send resident out. Contacted [hospital] who reported patient is currently admitted to ICU with vomiting from ingesting toxic chemical (Gain laundry pods). Daughter was contacted and notified. Review of facility documentation revealed a witness statement from nurse aide Employee 13 dated November 17, 2023, indicating: I was rounding went into [Resident 222's] room at 1530 found [laundry detergent] pods on bedside cabinet ripped open. I suspected that the patient ripped the bag open. I found 1-2 open on the floor. [Licensed Nurse Employee 11] brought [Resident 222] out to nurses station. He seemed ok. Around dinner time he started having loose stools. I went to get towels to clean it up. [Licensed Nurse Employee 11] was at nurses station. She kept sitting there even though she knew [Resident 222] was having loose stools. I had to get [another nurse aide] to help me. We cleaned him up and put him in bed. At 7:30 he sat up - he had vomited. I got [Licensed Nurse Employee 12] & I showered him again. I asked [Licensed Nurse Employee 12] if we need to call poison control. She said she was calling [provider.] [Emergency Medical Services] arrived about 9pm. Further review of nurse aide Employee 13's witness statement revealed: I reported the findings of the ripped open bag of pods to nurse @1550. I reported the diarrhea at dinner time. Further review of facility documentation revealed a witness statement from Licensed Nurse Employee 11, undated, which revealed: Nurse made aware by [nurse aide] at 6pm that patient had an opened bag of laundry pads [pods] in his room. Patient was found sitting in the chair in his room. [Vital signs stable.] No signs of distress or pain noted. Visualized [his] mouth and mucous membranes pink and moist. No abnormal smell noted. No residue around mouth or on his hands was noted. Inspected room, no signs that pods was used or tampered with. Patient brung out to the nurses station. Patient sat and flipped through a book. Snack was given. Consumed 100%. Report given to oncoming nurse. Review of Resident 222's clinical record failed to reveal documented evidence that the resident was assessed or vital signs were obtained following Nurse Aide Employee 13's witnessed account from 3:30 p.m. on November 16, 2023. Review of Resident 222's clinical record failed to reveal documented evidence the physician was notified at the time Resident 222's was found with an open laundry detergent pod. Review of Resident 222's clinical record and facility documentation revealed resident was unable to articulate if he/she ingested the contents of the laundry detergent pod due to impaired cognition and poor safety awareness. Review of Resident 222's clinical record and facility documentation failed to reveal evidence of staff contacting Poison Control or researching signs/symptoms of laundry detergent poisoning at the time Resident 222 was observed with open laundry deteregent pod and possible ingestion of the contents. Review of Resident 222's emergency room notes revealed: Reported to be found by staff at 1500 today with an open bag of laundry detergent pods next to him [Patient] reported to be vomiting and having diarrhea-unknown time of onset EMS dispatched at 2113 for a poisoning- arrived at 2123 to find [patient] 78% on Room air [(normal is 95-100%] , sitting up in a recliner slumped over. [Patient] arrives on nebulizer, slumped forward, emesis [(vomit)] bag with bright orange emesis with odor of detergent. Review of Resident 222's discharge summary from the hospital on November 29, 2023, revealed the resident was admitted to the ICU on high flow nasal cannula oxygen, placed on IV fluids and IV antibiotics, had a chest x-ray that showed aspiration (when fluids or stomach contents are breathed into the lungs), placed on bronchodilators (medications that relax the muscles around your airways and help clear mucus from your lungs) every 4 hours, and required frequent suctioning. Interview with the Interim Nursing Home Administrator and Corporate Nurse on March 15, 2024, at 9:35 a.m. confirmed the (nursing agency) staff failed to timely assess, monitor, and treat Resident 222 for suspected laundry detergent poisoning. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa Code 211.5(f) Clinical Records 28 PA Code 211.10(a) Resident care policies

Based on review of facility policy, clinical record, and facility documentation, it was determined that the facility failed to ensure a cognitively impaired resident's (Resident 222) environment was free from known environmental hazards including laundry detergent pods resulting in actual harm of suspected poisoning and subsequent hospitalization to the Intensive Care Unit (ICU) for one of 22 residents reviewed. Findings include: Review of facility policy, Poisoning, effective December 1, 2006, revealed: Upon discovery of suspected poisoning, call for help and instruct staff to call 911. Review of Resident 222's clinical record revealed a diagnosis of Dementia (loss of cognitive functioning that interferes with daily life and activities) with behavioral disturbances. Review of Resident 222's July 2023 admission MDS (Minimum Data Set - periodic assessment of resident care needs) revealed a BIMS (Brief Interview of Mental Status) was unable to be completed due to the resident's cognitive impairment. Review of Resident 222's clinical record revealed a nursing progress note dated November 13, 2023 (15:49 aka 3:49 p.m) indicating pt [patient] AAOx1 [Awake/Alert/Oriented x1] w/ hx [with history] of adv [advanced] dementia. steady gait, able to ambulate independently. impulsive, often wanders and tries to enter other patients' rooms. no s/s [signs/symptoms] of respiratory distress or sob [shortness of breath]. no c/o [complaints of] pain or discomfort. [resident] accepted [his/her] medications crushed with applesauce this morning. pt often refuses care. pt is grossly incontinent and often refuses incontinence care. becomes combative and agitated w/ at times. [Resident] is unable to make [resident] needs known. needs anticipated. call bell within reach. Review of Resident 222's nursing progress notes revealed a nursing note from Licensed Nurse Employee E12 dated November 17, 2023, at 1:44 a.m., indicating: Previous nurse [(Licensed Nurse Employee 11)] reported that resident was found with laundry pods around 1530 [(3:30 p.m.)] opened in his room. Nurse reported he seemed fine. About 2030 [(8:30 p.m.)] an aide needed assistance with incontinent care for resident. When I entered the room, resident was sitting on [the bed] with vomit and feces noted around him. Resident was alert. Resident was given a shower assessed and vitals were taken. Resident was able to follow commands during assessment. On call was contacted and spoke with [provider] who gave order to send resident out. Contacted [hospital] who reported patient is currently admitted to ICU with vomiting from ingesting toxic chemical (Gain laundry pods). Daughter was contacted and notified. Review of facility documentation revealed a witness statement from nurse aide Employee 13 dated November 17, 2023, indicating: I was rounding went into [Resident 222's] room at 1530 found [laundry detergent] pods on bedside cabinet ripped open. I suspected that the patient ripped the bag open. I found 1-2 open on the floor. [Licensed Nurse Employee 11] brought [Resident 222] out to nurses station. He seemed ok. Around dinner time he started having loose stools. I went to get towels to clean it up. [Licensed Nurse Employee 11] was at nurses station. She kept sitting there even though she knew [Resident 222] was having loose stools. I had to get [another nurse aide] to help me. We cleaned him up and put him in bed. At 7:30 he sat up - he had vomited. I got [Licensed Nurse Employee 12] & I showered him again. I asked [Licensed Nurse Employee 12] if we need to call poison control. She said she was calling [provider.] [Emergency Medical Services] arrived about 9pm. Further review of nurse aide Employee 13's witness statement revealed: I reported the findings of the ripped open bag of pods to nurse @1550. I reported the diarrhea at dinner time. Further review of facility documentation revealed a witness statement from Licensed Nurse Employee 11, undated, which revealed: Nurse made aware by [nurse aide] at 6pm that patient had an opened bag of laundry pads [pods] in his room. Patient was found sitting in the chair in his room. [Vital signs stable.] No signs of distress or pain noted. Visualized [his] mouth and mucous membranes pink and moist. No abnormal smell noted. No residue around mouth or on his hands was noted. Inspected room, no signs that pods was used or tampered with. Patient brung out to the nurses station. Patient sat and flipped through a book. Snack was given. Consumed 100%. Report given to oncoming nurse. Review of Resident 222's clinical record failed to reveal documented evidence that the resident was assessed or vital signs were obtained following Nurse Aide Employee 13's witnessed account from 3:30 p.m. on November 16, 2023. Review of Resident 222's clinical record failed to reveal documented evidence the physician was notified at the time Resident 222 was found with an open laundry detergent pod. Review of Resident 222's clinical record and facility documentation failed to reveal evidence of staff contacting Poison Control or researching signs/symptoms of laundry detergent poisoning at the time of Resident 222's suspected ingestion of the laundry detergent pod contents. Review of Resident 222's emergency room notes revealed: Reported to be found by staff at 1500 today with an open bag of laundry detergent pods next to him [Patient] reported to be vomiting and having diarrhea-unknown time of onset EMS dispatched at 2113 for a poisoning- arrived at 2123 to find [patient] 78% on Room air [(normal is 95-100%] , sitting up in a recliner slumped over. [Patient] arrives on nebulizer, slumped forward, emesis [(vomit)] bag with bright orange emesis with odor of detergent. Review of Resident 222's discharge summary from the hospital on November 29, 2023, revealed the resident was admitted to the ICU on high flow nasal cannula oxygen, placed on IV fluids and IV antibiotics, had a chest x-ray that showed aspiration (when fluids or stomach contents are breathed into the lungs), placed on bronchodilators (medications that relax the muscles around your airways and help clear mucus from your lungs) every 4 hours, and required frequent suctioning. Interview with the Interim Nursing Home Administrator and Corporate Nurse on March 15, 2024, at 9:35 a.m. when the above information was presented for staff failed to ensure a safe environment for cognitively impaired Resident 222 from ingesting laundry pod contents and timely assess, monitor, and treat suspected poisoning. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa Code 211.5(f) Clinical Records 28 PA Code 211.10(a) Resident care policies

Based on facility's policy, clinical records, facility investigation reviews; and staff interviews, it was determined that the facility failed to follow policy and procedures for hot beverages for one resident resulting in harm of a third-degree burn (injury that involves the outer layer of the skin and part of the inner layer of the skin) for one resident reviewed (Resident 1). Findings include: Review of the facility's policy titled Guidelines for Hot Beverages, with a revision date of August 1, 2008, revealed, when serving hot liquids to patients/residents, the following should be considered: Beverages should be dispensed in a plastic or China mug; no Styrofoam cups. Observations conducted on December 18, 2023 and December 19, 2023 revealed the facility had a beverage center located on the unit, where dietary staff place carafes of coffee. Review of Resident 1's clinical record revealed diagnoses including but not limited to difficulty in walking, Hypertension (high blood pressure), type 2 Diabetes Mellitus (metabolic disorder in which the body has high sugar levels for prolonged periods of time) with hyperglycemia, Major Depressive (mood disorder that causes a persistent feeling of sadness and loss of interest) disorder, Chronic Obstructive Pulmonary Disease (COPD - progressive lung disease characterized by long-term respiratory symptoms and airflow limitation), and Hypothyroidism (thyroid gland doesn't make enough thyroid hormone which may cause fatigue, weight gain, and depression). Review of Resident 1's clinical record including Medicare 5-day MDS (Minimum Data Set - assessment of resident clinical needs), dated November 9, 2023, revealed resident identified with a BIMS (Brief Interview of Mental Status) of 12 indicating resident has (mild/moderate) cognitive impairment. Review of information dated December 4, 2023, submitted by the facility on December 4, 2023, revealed that on December 1, 2023, Resident 1 requested coffee from the speech therapist, and while holding the cup, Resident 1's hand shook causing the coffee to spill on Resident 1's lap, which caused redness to [resident]'s right thigh. This event was witnessed by the speech therapist, who notified the nurse and the medical provider. The provider examined Resident 1 and applied ice to the area. Review of witness statement written by Employee E4 Speech Therapist, revealed that Resident 1 requested coffee prior to completing speech therapy exercise. Resident 1 was on a thin liquid diet. Resident 1 was observed with hot coffee via cup sips previously with no overt signs or symptoms of aspiration. The coffee was retrieved from a carafe on the unit. The coffee was served directly to Resident 1 in a Styrofoam cup which did not have a lid. When Resident 1 attempted to place the coffee cup on her table, Resident 1's hand jerked causing the coffee to spill on Resident 1's right hip and leg. Resident 1's pants were promptly removed. Resident 1 was then examined by a licensed nurse. Interview with Resident 1 on December 18, 2023 revealed, R1 stated that after he/she took a sip of his/her coffee he/she went to place the cup on his/her bedside table, resident missed the table and the coffee spilled on his/her lap, burning the leg. Review of the Wound Evaluation report dated December 14, 2023, revealed the third-degree burn to the front right trochanter (hip), was acquired in-house, and had a measurement of 6.6 x 15.4 cm (centimeters) with a total area of 67.9 cm. The wound was treated with Silvadene cream (an anti-microbial medication used to treat and prevent wound infection in patients with burns). Interview with Dietary Aide Employee E3, on December 18, 2023, at 10:58 a.m., revealed that at the time of the incident the facility did not have plastic lids for the beverage cup, therefore dietary staff used plastic wrap instead. Interview with interim Nursing Home Administrator on December 18, 2023, at 10:45 a.m., indicated the facility records food and beverage temperatures prior to service at the point of dispensation (in the kitchen). The Nursing Home Administrator indicated that the hot water used to make coffee come from a dispensing machine. The machine indicates temperature of brewing which was 190 degrees. The dietary staff add water and coffee crystals to a carafe for continue the process. Dietary staff allow the hot beverage to steep and cool before dispensing into serving cups. Further interview with Nursing Home Administrator on December 18, 2023, indicated that the dispensing machine brewing temperature was lowered to 160 degrees after the incident. Interview with Interim Nursing Home Administrator on December 18, 2023, at 12:50 p.m., confirmed the resident received a third degree burn after spilling coffee on thigh. Further interview with NHA revealed the employee who provided Resident 1 with the hot coffee was an agency employee, who will be required to complete the hot beverage training before working with residents at the facility in the future. Interview conducted with Employee E1, dietary staff on December 19, 2023, at 10:28 AM revealed food and beverage temperatures are recorded, reviewed and then are shredded at the end of the month. Further interview with Employee E1 revealed on the day of the incident, lids for Styrofoam cups could not be located. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services