Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident representative in advance of the risks and benefits of a psychotropic medication (medications that affect the persons mental state, emotions and behavior) use and the treatment alternatives prior to initiating the administration of the medication for two of 5 residents reviewed (Resident 1 and 5).Findings Include: The facility's policy related to the use of psychotropic medications, dated April 23, 2025, indicated that prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medications, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use (e.g., written consent form, narrative note, etc.). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 30, 2025, revealed that the resident was severely cognitively impaired, received antipsychotic and antianxiety medications, and had diagnoses that included dementia and anxiety. A skilled nursing facility psychiatric visit dated March 25, 2025, indicated that Resident 1 was seen for ongoing agitation, was up yelling and was difficult to redirect at night. Start five milligrams (mg) of Buspar (medication to treat anxiety) three times a day. Patient consents for the use of current medications to be obtained with social services. Physician's orders for Resident 1, dated March 27 2025, revealed that the resident was to receive five mg of buspirone three times a day for dementia with agitation. There was no documented evidence in the resident's clinical record to indicate that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the dose of Buspar. Interview with the Director of Nursing on September 4, 2025, at 2:54 p.m., confirmed that there was no documented evidence in the Resident' 1s clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating Buspar medication. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated May 13, 2025, revealed that she was cognitively impaired, required assistance with care needs, received antipsychotic, antianxiety, and antidepressant medications (psychotropic medications) and had diagnoses that included dementia, depression, and anxiety. A physician's note for Resident 5, dated May 14, 2025, at 8:48 p.m. revealed that the resident experienced a sudden behavioral escalation. Psychiatry was consulted and increased her Seroquel (antipsychotic medication used to treat mental health disorders) dose to 250 milligrams (mg). Physician's orders for Resident 5, dated May 15, 2025, included an order for the resident to receive 250 mg of Seroquel in the evening related to dementia with agitation. There was no documented evidence in the resident's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Seroquel. A nursing note for Resident 5, dated May 27, 2025, at 2:11 p.m. revealed that Certified Physician's Assistant (CRNP- registered nurse with advanced education and training who can diagnose, treat and prescribe medication) with psychiatric services was called and updated with the resident's increased agitation and a medication change was ordered to add 50 mg of Seroquel twice daily in addition to the 250 mg of Seroquel daily in the evening. Physician's orders for Resident 5, dated May 27, 2025, included an order for the resident to receive two 25 mg tablets of Seroquel to equal 50 mg twice daily related to dementia with agitation. There was no documented evidence in the resident's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Seroquel. Interview with the Director of Nursing on September 4, 2025, at 3:25 p.m., confirmed that a nursing note, dated May 15, 2025, at 1:30 p.m. and a nursing note, dated May 27, 2025, at 2:13 p.m. indicated that Resident 5's representative was notified of the dosage changes to Seroquel; however, there was no documented evidence in the resident's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased doses of Seroquel.

Based on a review of facility policies and clinical records as well as staff interviews, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication (drugs that affect a person's mental state, emotions, and behavior) for two of 5 residents reviewed (Residents 1 and 5). Findings Include: The facility policy related to the use of psychotropic medications, dated April 23, 2025, indicated that residents will only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. Nonpharmacological approaches must be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 30, 2025, revealed that the resident was severely cognitively impaired, was sometime understood, could sometimes understand, received antipsychotic and antianxiety medications, and had diagnoses that included dementia and anxiety. A skilled nursing facility psychiatric visit, dated March 25, 2025, indicated that Resident 1 was seen for ongoing agitation, was up yelling, and was difficult to redirect at night. Nonpharmacological interventions were to be used for this resident. Physician's orders for Resident 1, dated May 19, 2025 and June 11, 2025, revealed that the resident was to receive 0.25 milligrams (mg) of Alprazolam (a psychotropic medication) every eight hours as needed for anxiety. Review of Resident 1's Medication Administration Record (MAR) for May and June 2025, revealed that the resident received 0.25 mg of Alprazolam on May 19 at 2:41 p.m., on May 20 a.m at 10:17 a.m., on May 21 at 2:50 a.m., on June 11 at 1:50 p.m, on June 17 at 12:20 a.m., and on June 19 at 11:30 p.m. A review of Resident 1's clinical record revealed no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed Alprazolam on the above-mentioned dated and times. Interview with the Director of Nursing on September 4, 2025, at 2:54 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted prior to administering as needed Alprazolam to Resident 1 on the above-mentioned dates/times. An admission MDS assessment for Resident 5, dated May 13, 2025, revealed that she was cognitively impaired, required assistance with care needs, received antipsychotic, antianxiety, and antidepressant medications (psychotropic medications) and had diagnoses that included dementia, depression, and anxiety. Physician's orders for Resident 5, dated May 9, 2025, revealed that the resident was to receive 0.5 milligrams (mg) of Lorazepam (a psychotropic medication) every eight hours, may use three times daily, as needed for anxiety. Physician's orders for Resident 5, dated May 24, 2025, included an order for the resident to receive 0.5 mg of Lorazepam three times daily as needed for anxiety. Physician's orders for Resident 5, dated May 27, 2025, June 8, 2025, and June 24, 2025, included orders for the resident to receive 0.5 mg of Lorazepam every eight hours as needed for anxiety. Physician's orders for Resident 5, dated July 10, 2025, July 24, 2025, July 30, 2025, revealed that the resident was to receive 0.5 mg of Lorazepam every eight hours, may use three times daily, as needed for anxiety. Physician's orders for Resident 5, dated August 8, 2025, and August 25, 2025, revealed that the resident was to receive 0.5 mg of Lorazepam every eight hours as needed for anxiety. Review of Resident 5's Medication Administration Record (MAR) for May, 2025 through August, 2025, revealed that the resident received 0.5 mg of Lorazepam on May 10 at 1:20 p.m.; May 14 at 11:20 p.m.; May 18 at 10:01 a.m.; May 23 at 5:58 p.m.; May 27 at 7:15 p.m.; May 28 at 8:15 a.m.; May 31 at 3:38 p.m.; June 2 at 8:33 a.m.; June 3 at 8:11 a.m.; June 6 at 3:56 p.m.; June 10 at 3:43 p.m.; June 14 at 4:10 p.m.; July 10 at 5:48 p.m.; July 29 at 12:05 p.m.; August 14 at 2:15 p.m.; August 21 at 12:14 p.m.; and August 25 at 2:22 p.m. Review of Resident 5's clinical record, revealed no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed Lorazepam on the above-mentioned dated and times. Interview with the Director of Nursing on September 4, 2025, at 3:25 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted prior to administering as needed Lorazepam to Resident 5 on the above-mentioned dates/times. 28 Pa. Code 211.2(d)(3) Medical director 28 Pa. Code: 211.9(a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's representative/interested family member was notified timely about the need to alter treatment/changes in physician's orders for one of seven residents reviewed (Resident 7). Findings include: The facility's policy regarding charting and documentation, dated July 25, 2024, indicated that documentation of procedures and treatments will include care-specific details, including notification of family, physician, or other staff, if indicated. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 7, dated December 2, 2024, revealed that the resident was understood, understands with a Brief Interview for Mental Status score (BIMs - intended to determine the resident's attention, orientation and ability to register and recall new information and whether the resident has signs and symptoms of delirium) of 10, indicating that the resident was moderately impaired, and had a diagnosis which included Parkinson's disease and dementia. A care plan for the resident, dated August 27, 2021, revealed that the resident has an Advanced Directive (a written statement of a person's wishes regarding medical treatment) and staff were to keep the family informed of changes in condition. The resident's clinical record revealed that Resident Family Member 1 was the resident's power of attorney (a person legally authorized to make decisions for someone else), emergency contact, and was an interested family member. Physician's orders for Resident 7, dated December 17, 2024, included an order for the resident to receive one 20 milligram (mg) tablet of Paxil (an antidepressant) one time a day for psychosis (a set of symptoms that affect a person's ability to distinguish reality from what is not real). Physician's orders for Resident 7, dated January 2, 2025, included an order for the resident to receive one 25 mg capsule of Anafranil (an antidepressant medication that treats obsessive-compulsive disorder) at bedtime for obsessive-compulsive disorder. There was no documented evidence that Resident 7 instructed the facility not to contact Resident Family Member 1, and no documented evidence that Resident Family Member 1 was notified about the physician's orders on December 17, 2024, and January 2, 2025. Interview with the Director of Nursing on January 15, 2025, at 2:25 p.m. confirmed that Resident Family Member 1 was not notified about the above changes in Resident 7's treatment. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for one of seven residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 20, 2024, revealed that the resident was understood, could understand others, and had a Crohn's disease (a chronic inflammatory bowel disease that causes inflammation in the digestive tract), diabetes (a chronic disease that occurs when the body can not produce or use insulin properly, resulting in high blood sugar levels), and hemiplegia (a neurological condition that causes paralysis or weakness on one side of the body). The resident's clinical record revealed that Resident Family Member 2 (son) and Resident Family Member 3 (daughter-in-law) were the resident's emergency contacts and were interested family members. A nursing note for Resident 2, completed by Registered Nurse 1 and dated January 6, 2025, at 8:00 a.m., revealed that Resident Family Member 3 was at the nurses' station stating, I want her sent out. Upon assessment, the resident was awake, alert, and oriented to self. Resident 2 stated that she was in the emergency room. Her skin was warm and dry, her cheeks were ruddy. She was afebrile (no increased temperature), and her vital signs were stable. Physician 2 was made aware, and no new orders were received. There was no documented evidence in the clinical record to indicate that Resident 2 was sent to the hospital per Resident Family Member 3's (daughter-in-law) request. Interview with Physician 2 on January 14, 2025, at 1:42 p.m. revealed that when he received a text regarding Resident 2, he gave an order to send the resident out to the hospital at that time. He then received a text that said the resident was not going out to the hospital. He indicated that he was not aware of what changed as to why they did not send her out to the hospital at that time. Interview with the Regional Director of Clinical Services 5 on January 14, 2025, at 2:05 p.m. confirmed that the resident was not sent out to the hospital on January 6, 2025. Interview with Registered Nurse 1 on January 14, 2025, at 2:30 p.m. revealed that Resident Family Member 3 came to her and told her that she thought that the resident was having a stroke. She indicated that she went back to assess the resident and saw that the resident was not in any distress. She indicated that she did not see anything that would indicate a stroke. She indicated that before she was able to get the order in to send the resident out to the hospital the Director of Nursing came out and said that she was going to go back and assess the resident. When she came back, she said they are not sending the resident out. She indicated that she did not put the order in the electronic medical record because the Director of Nursing said that they were not sending her out, so why put the order in. She indicated that she contacted the resident's son that she had all the paperwork and that she was going to send his mother out to the hospital. Interview with the Director of Nursing on January 14, 2025, at 3:03 p.m. revealed that someone came to her office and indicated that Resident 2 was being sent out to the hospital. They said that the family went to Registered Nurse 1 and told her that the resident was a little off. So, she went back to see the resident. She indicated that she sat on the bed and spoke with the resident, and the resident did not look to be in any distress. She then told Registered Nurse 1 to go and do her assessment and then to notify the physician and the resident's family. She indicated that she went back to her office and had very little involvement after that. Interview with Licensed Practical Nurse 3 on January 14, 2025, at 3:15 p.m. revealed that he worked over from the night shift that night and he was waiting to do count with Registered Nurse 1 when someone came up to Registered Nurse 1 indicating that Resident 2 did seem like herself. Registered Nurse 1 asked me to go with her because she was relatively new to the facility and does not know all the residents. The resident thought she was in the emergency room. So, they returned to the nurses' station and Registered Nurse 4, who was the night shift supervisor, was still there, so she began helping Registered Nurse 1 with the transfer paperwork for the resident. He indicated that when he was leaving around 8:00 a.m. he was under the impression that they were sending the resident to the hospital. Interview with Registered Nurse 4 on January 14, 2025, at 3:28 p.m. revealed that she gave report to Registered Nurse 1 when she came in for the daylight shift. Then someone came up to Registered Nurse 1 and indicated that Resident 2 was incoherent and wanted her sent out to the hospital and that that person was going to call someone. Registered Nurse 1 then went back to assess the resident and when she came back, she was trying to get papers around to send her out to the hospital, so Registered Nurse 4 helped her. The Director of Nursing was there, and she went back to see the resident. When the Director of Nursing returned, she indicated that she thought the resident did not need to be sent out. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of seven residents reviewed (Resident 2). Findings Include: The facility's policy regarding charting and documentation, dated July 25, 2024, indicated that documentation in the medical record will be objective, complete, and accurate. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 20, 2024, revealed that the resident was understood, could understand others, and had Crohn's disease (a chronic inflammatory bowel disease that causes inflammation in the digestive tract), diabetes (a chronic disease that occurs when the body can not produce or use insulin properly, resulting in high blood sugar levels), and hemiplegia (a neurological condition that causes paralysis or weakness on one side of the body). The resident's clinical record revealed that Resident Family Member 2 (son) and Resident Family Member 3 (daughter-in-law) were the resident's emergency contacts and were interested family members. A nursing note for Resident 2, completed by Registered Nurse 1, dated January 6, 2025, at 8:00 a.m., revealed that Resident Family Member 3 was at the nurses' station stating, I want her sent out. Upon assessment, the resident was awake, alert, and oriented to self. She stated that she was in the emergency room. Her skin was warm and dry, cheeks ruddy. She was afebrile (no increased temperature), and her vital signs were stable. Physician 2 was made aware, and no new orders were received. A statement completed by Registered Nurse 1, dated January 9, 2025, revealed that on January 6, 2025, at approximately 8:00 a.m. she entered Resident 2's room due to Resident Family Member 3 stating she felt that the resident was having a stroke. The resident was lying in bed with no visible signs of distress. The resident was awake, alert, her smile was symmetrical, her tongue was mid-line, her hand grasps and pedal pulses equal and strong. Her vital signs were stable. She then spoke with Resident Family Member 2 when he called in, informed him of the assessment, and that if there was something they can treat there, they would do so. A statement completed by the Director of Nursing, dated January 9, 2025, revealed that approximately 8:30 a.m. on January 6, 2025, she was notified that the family was questioning if Resident 2 should be transferred to the hospital. She walked back to the resident's room to visualize her status. At that time, she was alert and oriented and talking and did not appear to be in any distress. The Director of Nursing conferred with Registered Nurse 1, who stated that she assessed the resident, and she also did not see that the resident was in any distress. Interview with Physician 2 on January 14, 2025, at 1:42 p.m. revealed that when he received a text regarding Resident 2, he gave an order to send the resident out to the hospital at that time. He then received a text that said the resident was not going out to the hospital. He indicated that he was not aware of what changed as to why they did not send her out to the hospital at that time. There was no documented evidence that the assessments of Resident 2 by Registered Nurse 1 and the Director of Nursing, or the physician's orders to send the resident to the hospital were in the resident's clinical record. Interview with the Regional Director of Clinical Services 5 on January 14, 2025, at 2:05 p.m. revealed that they spoke with Registered Nurse 1 regarding the morning of January 6, 2025, as well as had her write a statement after a family member voiced a grievance. Registered Nurse 1's statement indicated that she was assessing for a stroke and she was asked why that part of the assessment was not documented in the medical record. Registered Nurse 1 told them that she forgot to go back into the electronic medical record to update her note. She also confirmed that the physician's order for Resident 2 to be sent out to the hospital was not in the resident's clinical record and that Registered Nurse 1's assessments from her statement were not in the clinical record. Interview with Registered Nurse 1 on January 14, 2025, at 2:30 p.m. she indicated that she went back throughout her shift to re-evaluate the resident on January 6, 2025. She confirmed that she did not put the physician's orders for her to be transferred out to the hospital or her re-evaluation assessments throughout her shift in the electronic medical record for Resident 2, as well as go back in to update her note from January 6, 2025, with her assessment finding as stated in her statement from January 9, 2025. 28 Pa. Code 211.5(f) Clinical Records.

Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a professional licensure check prior to hire for one of one licensed practical nurse reviewed (Licensed Practical Nurse 1). Findings include: The facility's abuse policy, dated August 27, 2024, indicated that the facility will not employ individuals that had a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. Review of personnel file for Licensed Practical Nurse 1 revealed that she was hired on September 3, 2024, and the Pennsylvania Professional Licensure check was not verified until November 4, 2024, two months after she was hired. Interview with Director of Human Resources on November 5, 2024, at 11:05 a.m. confirmed that the license check for Licensed Practical Nurse 1 was not done timely. She stated that she accidently ran the check on her graduate license and not her permanent license as she should. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of the Resident Assessment Instrument (RAI) User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set (MDS) assessments for three of 35 residents reviewed (Residents 3, 9, 29). Findings include: The Resident Assessment Instrument User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that Section N0350 Insulin (medication used to lower blood sugar) was to be coded if the resident received insulin during the seven-day look-back period. Section N0350A was to be coded with the number of days the resident received insulin injections during the look-back period. Physician's orders for Resident 3, dated September 11, 2024, included an order for the resident to receive 1.8 milligrams (mg) of Victoza (non-insulin medication used to treat diabetes) subcutaneously (beneath the skin) one time a day. Review of the Medication Administration Record (MAR) for Resident 3, dated September 2024, revealed that the resident received Victoza every day during the look-back period. An admission MDS assessment for Resident 3, dated September 17, 2024, revealed that Section N0350A was coded, indicating that the resident received receive insulin. Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on November 6, 2024, at 12:05 p.m. confirmed that Victoza was not an insulin and the MDS assessment for Resident 3 was coded incorrectly. The RAI User's Manual, dated October 2023, revealed that Section N0410F (1) (Antibiotic Medications) was to be coded if the resident received an antibiotic medication during the seven-day assessment period. Physician's orders for Resident 9, dated December 13, 2023, included an order for the resident to have 1 percent silver sulfadiazine (Silvadene-topical antibiotic) applied to his buttocks and scrotum every day and evening for redness. The resident's Treatment Administration Records (TAR's) for August 2024 revealed that the resident received Silvadene twice a day during the look-back period. A quarterly MDS assessment for Resident 9, dated August 19, 2024, revealed that Section N0410F(1) was coded (0), indicating that the resident did not receive any antibiotic medications during the seven days of the assessment period. Interview with the RNAC on November 6, 2024 at 12:05 p.m. confirmed that the MDS assessment for Resident 9 was coded incorrectly. The RAI User's Manual, dated October 2023, revealed that Section N0415J Hypoglycemic Medications (medications used to treat diabetes) was to be coded if the resident took the medication during the seven-day look-back period. Section N0415J Hypoglycemic (including insulin) Medication Review was to be coded (1) if the resident received the medication during the look-back period. Physician's orders for Resident 29, dated June 4, 2024, included an order for the resident to receive 40 units Glargine insulin at bedtime and 7 units every morning, and an order, dated June 5, 2024, for the resident to receive insulin coverage before meals and at bedtime based on her blood sugar reading. Review of the Medication Administration Record (MAR) for Resident 29, dated September 2024, revealed that she received insulin every day during the look-back period. An annual MDS assessment for Resident 29, dated September 11, 2024, revealed that Section N0415J was not coded, indicating that the resident did not receive a hypoglycemic medication. Interview with the RNAC on November 6, 2024 at 12:05 p.m. confirmed that the MDS assessment for Resident 29 was coded incorrectly. 28 Pa. Code 211.5(f) Clinical Records.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was created to reflect the resident's specific care needs for two of 35 residents reviewed (Residents 19, 82). A facility policy regarding care plans, dated August 27, 2024, revealed that care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Care plan goals and objectives were derived from information contained in the resident's comprehensive assessment. A facility policy regarding tobacco-free policy, dated October 29, 2024, revealed that the facility was tobacco free, and the facility prohibits the possession and/or storage of all smoking/smokeless tobacco materials. However, any resident admitted to the facility prior to the effective date of this policy would be Grandfathered into the prior policy and procedure. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated October 2, 2024, revealed that the resident was cognitively intact, was clearly understood and able to understand others, required assistance with care needs, and had a diagnosis of quadriplegia (condition that causes a complete or severe loss of motor function in all four limbs). Observations and interview of Resident 19 on November 7, 2024, at 9:04 a.m., revealed that the resident was lying in bed using a tablet. On this over-bed table was a can of smokeless tobacco pouches and a Styrofoam cup with a tissue and brown substance inside. The resident confirmed that he used smokeless tobacco. Interview with the Director of Nursing on November 7, 2024, at 12:02 p.m. confirmed that Resident 19 did not have a care plan developed to reflect the resident's use of smokeless tobacco, and should have. Physician's orders for Resident 82, dated November 3 and 5, 2024, included orders for the resident to receive 1 gram of meropenem (antibiotic) intravenously (IV - directly into a vein) every 12 hours until November 11, 2024. Physician's orders, dated November 1, 2024, included an order for the IV catheter be flushed with a minimum of 10 cubic centimeters (cc's) of 0.9 percent sodium chloride (sterile salt water solution) every shift and before and after medication administration, and to measure the circumference in centimeters (cm) of the upper arm at the peripherally inserted central catheter (PICC line - a type of catheter that is inserted through a peripheral vein and used long-term to administer medications and/or fluids) insertion site every shift and as needed. Resident 82's Medication Administration Record (MAR) for November 2024 revealed that the resident received IV meropenem on November 3 through 7, 2024; had her PICC line flushed with normal saline solution every shift and before and after each administration; and had the circumference of her upper arm measured every shift. There was no documented evidence that a care plan was developed to address Resident 82's PICC line and need for IV antibiotics. Interview with the Director of Nursing on November 7, 2024, at 9:52 a.m. confirmed that there was no documented evidence that a care plan was developed for the care of Resident 82's PICC line and the need for antibiotics. 28 Pa. Code 201.24(e)(4) admission Policy. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcer treatments were provided to prevent infection for one of 35 residents reviewed (Resident 19). Findings include: A facility policy regarding pressure ulcer/skin breakdown clinical protocol policy, dated August 27, 2024, revealed that the physician would authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings, and applications of topical agents, if indicated for type of skin alteration. A facility policy regarding handwashing/hand hygiene policy, dated August 27, 2024, revealed that staff were to use alcohol-based hand rub containing at least 62 percent alcohol or, alternatively, soap and water after handling clean or soiled dressings and gauze pads. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated October 2, 2024, revealed that the resident was cognitively intact, was clearly understood and able to understand others, required assistance with care needs, had a diagnosis of quadriplegia (condition that causes a complete or severe loss of motor function in all four limbs), and had one facility-acquired Stage III pressure ulcer (full-thickness tissue loss that extends into deeper tissue and fat). A pressure ulcer investigation for Resident 19, dated August 21, 2024, revealed that there was an open area on the left inner heel. Resident 19 indicated that his heels were rubbing against the back of his foot rest on the wheelchair. Physician's orders for Resident 19, dated October 18, 2024, included an order to cleanse the left heel with wound cleanser, then apply 500 unit/gram bacitracin antibiotic to the base of the wound, apply collagen to base of wound, secure with border dressing (an absorptive dressing bordered with adhesive) twice a day and as needed. Observations of wound care on November 7, 2024, at 9:48 a.m. revealed that Licensed Practical Nurse 2 used hand sanitizer, put on gown and gloves, removed the old dressing, sprayed wound cleanser on a gauze, and cleansed the wound. The gloves were visibly wet from the wound cleanser. After removing the soiled dressing and cleaning the wound, Licensed Practical Nurse 2 did not change gloves or perform hand hygiene. Using the same gloves Licensed Practical Nurse 2 applied the bacitracin and the collagen to the base of the wound, applied the boarded gauze, and wrapped the heel with Kerlix. Interview with Licensed Practical Nurse 2 on November 7, 2024, at 10:00 a.m. confirmed that she was to perform hand hygiene between dirty and clean tasks during wound care. Interview with the Infection Preventionist on November 7, 2024, at 10:09 a.m. confirmed that she would expect staff to change gloves and perform hand hygiene between dirty and clean tasks. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that physician-ordered contracture management interventions were provided as care planned for one of 35 residents reviewed (Resident 65). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 65, dated August 2, 2024, revealed that the resident was cognitively impaired, required extensive assist assistance from staff for personal hygiene, and had diagnosis that included hemiplegia/hemiparalysis (a medical condition that causes weakness or paralysis on one side of the body). Resident 65's care plan, dated March 5, 2024, indicated that the resident was to always have a rolled towel in her left hand, except during a.m. and p.m. care, and it was to be checked for placement and integrity. Physician's orders for Resident 65, dated June 5, 2024, revealed the resident was to always have a rolled towel in her left hand, and it was to be checked every shift for placement and integrity. Observations on November 4, 2024, at 9:32 a.m. and at 10:51 a.m. revealed that the resident did not have a rolled towel in her left hand as ordered. Interview with Nurse Aide 3 on November 4, 2024, at 10:57 a.m. revealed that the resident did not have a rolled towel in her left hand as ordered, and she should have. Interview with the Director of Nursing on November 5, 2024, at 10:00 a.m. confirmed that Resident 65 is to always have a rolled towel in her left hand, except during morning and evening care. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to complete safety assessments for one of 35 residents reviewed (Resident 47) who used an air mattress. Findings include: A facility policy regarding support surface guidelines, dated August 27, 2024, indicated that the facility would follow the guidelines for the assessment of appropriate pressure-reducing and relieving devices for residents at risk for skin break down. Support surfaces were critical to pressure ulcer prevention and general safety include pressured redistribution, moisture control, shear reduction, and life expectancy. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 47, dated June 29, 2024, revealed that the resident was usually understood, could usually understand others, was cognitively impaired, required assistance from staff for care needs, had a Stage 3 pressure ulcer (full thickness skin loss into the lower layers of skin) on admission, and received hospice services. Observations on November 7, 2024, at 9:33 a.m. revealed that Resident 47 was lying in bed and the bed was equipped with an air mattress; however, there was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to being placed on Resident 47's bed. Interview with the Director of Nursing on November 7, 2024, at 12:02 p.m. confirmed that there were no assessments for potential safety hazards prior to the air mattress being placed on the resident's bed and there should have been. Hospice staff placed the mattress and did not inform the facility. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that long-term intravenous catheters were flushed and arm circumference was measured as ordered for one of 35 residents reviewed (Resident 82). Findings include: The facility's policy regarding flushing central and midline catheters (a tube placed in a vein that can be used to deliver fluids and/or medications), dated August 27, 2024, revealed that when a resident was ordered intravenous medication, a 10 milliliter (ml) saline flush (a method used to clean a catheter of blood or medication) was to be administered before each medication was infused. Physician's orders for Resident 82, dated November 1, 2024, included an order for the peripherally-inserted central catheter (PICC line - a type of catheter that is inserted through a peripheral vein and used long-term to administer medications and/or fluids) be flushed with a minimum of 10 cubic centimeters (cc's) of 0.9 percent sodium chloride (sterile salt water solution) every shift, before and after medication administration, and to measure the circumference in centimeters (cm) of the upper arm at the PICC insertion site every shift and as needed. Physician's orders for Resident 82, dated November 3 and 5, 2024, included orders for the resident to receive 1 gram of meropenem (antibiotic) intravenously (IV - directly into a vein) every 12 hours until November 11, 2024. Resident 82's Medication Administration Record (MAR) for November 2024 revealed that the resident received IV meropenem on November 3 through 7, 2024; however, there was no documented evidence that staff flushed the resident's PICC line with normal saline solution every shift, before and after each medication administration, or that they measured the circumference of the resident's upper arm on November 2, 3, and 7, 2024. Interview with the Director of Nursing on November 7, 2024, at 9:52 a.m. confirmed that there was no documented evidence that Resident 82's PICC line was flushed every shift, before and after each medication administration, or that the resident's upper arm was measured on November 2, 3 and 7, 2024. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the physician wrote a progress note for each visit for one of 35 residents reviewed (Resident 15). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated August 16, 2024, indicated that the resident was cognitively intact and required maximum assistance from staff for care. A nurse's note for Resident 15, dated March 5, 2024, at 3:30 p.m., revealed that the resident was seen by the physician regarding her increased behaviors in the evening and increased meanness towards her family and spoke with the physician at length; however, there was no documented evidence of a provider's progress note in the clinical record. A nurse's note for Resident 15, dated March 14, 2024, at 2:09 p.m., revealed that the resident was examined by the physician at bedside; however, there was no documented evidence of a provider's progress note in the clinical record. A nurse's note for Resident 15, dated August 15, 2024, at 7:05 p.m., indicated that the resident's daughter was concerned about her mother and wanted her seen by the doctor. A physician's list of rounds, dated August 20, 2024, revealed that Resident 15 was seen by the doctor on August 15, 2024; however, there was no documented evidence of a provider's progress note in the clinical record. Interview with the Director of Nursing on November 7, 2024, at 1:52 p.m. confirmed that there were no physician's notes in the clinical record for Resident 15 on the dates listed. She also stated that the physician is very behind in his notes and they have to call the office if they need them. 28 Pa. Code 211.5(f) Clinical Records.

Based on review of facility policies, clinical records, and pharmacy labels for medications, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled and dated for one of 35 residents reviewed (Resident 19). Findings include: A facility policy regarding medication ordering and receiving from pharmacy policy, dated August 27, 2024, revealed that improper and inaccurate labeled medications were rejected and returned to the dispensing pharmacy. Medication labels were not to be altered, modified, or marked in any way by nursing personnel. If the physician's directions for use change or the label was inaccurate, the nurse may place a change or order - check chart label on the container indicating there is a change in directions for use, taking care not to cover important label information. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated October 2, 2024, revealed that the resident was cognitively intact, was clearly understood and able to understand others, required assistance with care needs, had a diagnosis of quadriplegia (condition that causes a complete or severe loss of motor function in all four limbs), and was taking opioid medication (narcotic medication). Physician's orders for Resident 19, dated September 26, 2024 included an order for the resident to receive 5-325 milligrams of hydrocodone-acetaminophen (narcotic pain medication) at bedtime for pain and every six hours as needed for moderate pain (4-6 out of 10). Observations of the B wing medication cart on November 6, 2024, at 2:15 p.m. revealed that the hydrocodone-acetaminophen medication card for Resident 19 had instruction to give one tablet every six hours as needed for pain with + HS written on the label in pen. There was no sticker on the medication label to indicate a change in order. Interview with Licensed Practical Nurse 4 at the time of the observation revealed that she was unsure why the label was written on with pen, as staff were not to alter the label unless there is a sticker added when the order changes. Interview with the Nursing Home Administrator on November 6, 2024, at 2:53 p.m. confirmed that the medication label that came from pharmacy for Resident 19's hydrocodone-acetaminophen should not have been altered. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1) Nursing Services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plan of correction for a State Survey and Certification (Department of Health) survey ending December 7, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending November 7, 2024, identified repeated deficiencies related to a failure to ensure that Minimum Data Sets (MDS, a mandated assessment of a resident's abilities and care needs) assessments were accurate upon submission, develop individualized care plans, and properly store and label medications. The facility's plan of correction for a deficiency regarding a failure to ensure that MDS's were accurate upon submission, cited during the survey ending December 7, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to accurate MDS assessments. The facility's plan of correction for a deficiency regarding the development of a comprehensive person-centered care plan, cited during a survey ending December 7, 2023, revealed that audits would be completed. The results of the current survey, cited under F656, revealed that the QAPI committee was ineffective in correcting deficient practices related to the development of a comprehensive person-centered care plan. The facility's plan of correction for a deficiency regarding storing/labeling medications properly, cited during the survey ending December 7, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to storing/labeling medications properly. Refer to F641, F656, F761. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident, the responsible party, and long-term care ombudsman in writing regarding the reason for hospitalization for seven of 35 residents reviewed (Residents 1, 19, 22, 27, 29, 53, 64). Findings include: A nursing note for Resident 1, dated September 27, 2024, at 12:52 a.m. revealed that the resident was admitted to the hospital with congestive heart failure (a medical condition where the heart is unable to pump enough blood to meet the body's needs). There was no documented evidence that a written notice of Resident 1's transfer to the hospital was provided to the emergency contact or the long-term care ombudsman regarding the reason for transfer. A nursing note for Resident 19, dated September 24, 2024, at 1:07 a.m., revealed that the resident was admitted to the hospital with urinary tract infection and possible pneumonia. There was no documented evidence that a written notice of Resident 19's transfer to the hospital was provided to the resident's emergency contact or the long-term care ombudsman regarding the reason for transfer. A nursing note for Resident 22, dated September 27, 2024, at 1:21 a.m., revealed that the resident was admitted to the hospital with hypoosmolarity hyperglycemic state (high blood sugar). There was no documented evidence that a written notice of Resident 22's transfer to the hospital was provided to the resident's responsible party or the long-term care ombudsman regarding the reason for transfer. A nursing note for Resident 27, dated September 22, 2024, at 5:54 p.m., revealed that the resident was lethargic and disoriented when talking, the physician was notified, and the resident was transferred to the hospital for evaluation. The resident was admitted to the hospital with pneumonia. There was no documented evidence that a written notice of Resident 27's transfer to the hospital was provided to the resident's responsible party or the long-term care ombudsman regarding the reason for transfer. A nursing note for Resident 29, dated June 1, 2024 at 6:43 a.m., revealed that the resident was admitted to the hospital with sepsis. There was no documented evidence that a written notice of Resident 29's transfer to the hospital was provided to the resident's responsible party or the long-term care ombudsman regarding the reason for transfer. A nursing note for Resident 53, dated June 3, 2024, at 8:33 p.m., revealed that the resident was admitted to the hospital with aspiration pneumonia (an infection of the lungs caused by inhaling saliva, food, liquid, and/or vomit). There was no documented evidence that a written notice of Resident 53's transfer to the hospital was provided to the resident's responsible party or long-term care ombudsman regarding the reason for transfer. A nursing note for Resident 64, dated July 21, 2024, at 9:58 a.m., revealed that the resident was transferred to the emergency room for evaluation after a change in mental condition. There was no documented evidence that a written notice of Resident 64's transfer to the hospital was provided to the resident's responsible party or long-term care ombudsman regarding the reason for transfer. Interview with the Director of Nursing on November 6, 2024, at 9:23 a.m. confirmed that the facility did not provide a written notice to Residents 1, 19, 22, 27, 29, 53, 64; the resident's emergency contacts/responsible parties; or the long-term care ombudsman when the residents were transferred to the hospital. 28 Pa. Code 201.25 Discharge Policy. 28 Pa. Code 201.29(f)(g) Resident Rights.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to the resident and/or the resident's representative at the time of a transfer for five of 35 residents reviewed (Residents 1, 22, 27, 29, 53). Findings include: A nursing note for Resident 1, dated September 27, 2024, at 12:52 a.m. revealed that the resident was admitted to the hospital with congestive heart failure (a medical condition where the heart is unable to pump enough blood to meet the body's needs). There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital for Resident 1. A nursing note for Resident 22, dated September 27, 2024, at 1:21 a.m., revealed that the resident was admitted to the hospital with hypoosmolarity hyperglycemic state (high blood sugar). There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital for Resident 22. A nursing note for Resident 27, dated September 22, 2024, at 5:54 p.m., revealed that the resident was lethargic and disoriented when talking, the physician was notified, and the resident was transferred to the hospital for evaluation. The resident was admitted to the hospital with pneumonia. There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital for Resident 27. A nursing note for Resident 29, dated June 1, 2024, at 6:43 a.m., revealed that the resident was admitted to the hospital with sepsis. There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital for Resident 29. A nursing note for Resident 53, dated June 3, 2024, at 8:33 p.m., revealed that the resident was admitted to the hospital with aspiration pneumonia (an infection of the lungs caused by inhaling saliva, food, liquid, and/or vomit). There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital for Resident 53. Interview with the Director of Nursing on November 6, 2024, at 9:23 a.m. confirmed that the facility did not provide a bed-hold notice to Residents 1, 22, 27, 29, 53 or to the resident's responsible parties when the residents were transferred to the hospital. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(3) Management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that the facility failed to maintain clinical records that were accurately documented for two of 35 residents reviewed (Residents 24, 45). Findings include: Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of 28 residents reviewed (Resident 24). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated July 5, 2024, indicated that the resident was cognitively impaired, was dependent on staff assistance for daily care needs, had a diagnosis of depression. Physician's orders for Resident 24, dated October 22, 2024, included orders for the resident to receive 0.5 mg of 2mg/ml Lorazepam (a medication to treat anxiety) every four hours as needed. Review of Resident 24's Medication Administration Record (MAR) for October 2024 revealed that the resident received 0.5 mg of lorazepam on October 25, 2024, at 1:56 a.m. and 4:29 a.m. Review of Resident 24's controlled drug accountability sheet for a 30.0 ml bottle of lorazepam (2mg/ml) revealed that the total amount remaining on October 25, 2024, at 4:29 a.m. was documented as 25.0 ml; however, observations of the bottle on November 6, 2024, at 1:42 p.m. revealed that there was 29.0 ml remaining in the bottle. Interview with Director of Nursing on November 7, 2024, at 8:43 a.m. confirmed that the amount remaining in the bottle was documented incorrectly. A quarterly MDS assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 45, dated October 11, 2024, revealed that the resident was cognitively intact. Resident 45's [NAME], undated, revealed that he preferred a shower. Resident 45's shower log, dated September and October 2024, revealed that there were 18 opportunities for a shower; however, only one shower was documented. An interview with Resident 45 on November 4, 2024, at 11:08 a.m. revealed that he receives his showers twice per week. Interview with the Director of Nursing on November 6, 2024, at 10:21 a.m. revealed that Resident 45's shower record was not in their charting system correctly; therefore, the staff could not accurately chart the resident's showers. 28 Pa. Code 211.5(f) Clinical Records.

Based on review of established infection control guidelines, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination during a COVID-19 outbreak and failed to follow infection control guidelines from CMS and the CDC for residents requiring Enhanced Barrier Precautions (EBP) for six of seven residents reviewed (Residents 1, 2, 3, 5, 6, 7). Findings include: The facility's policy regarding COVID-19 management, dated August 27, 2024, indicated that the facility follows current guidelines and recommendations for managing COVID-19 in the facility. This included ensuring the facility has all the necessary supplies, including personal protective equipment (PPE). The CDC recommends a 10-day isolation period for residents with suspected or confirmed COVID infection, and the door should be kept closed if safe to do so. CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization (germs living on/within a persons body that can be spread to others) with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. The facility's policy regarding EBP, dated August 27, 2024, indicated that the facility will use EBPs to prevent the spread of multidrug-resistant organisms (MDROs). EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy, or ventilator) and wound care. EBPs are indicated when a resident is infected or colonized with a MDRO. Review of electronic event reports submitted by the facility to the Department of Health, dated August 14, 20, 28, 30, and September 3, 5, 9, 10, 11, 13, and 15, 2024, revealed that a total of 10 staff members and 21 residents developed COVID infection between these dates. Record review revealed that two residents in the facility had active COVID at the time of the on-site visit on September 17, 2024. An admission nurse's note for Resident 1, dated September 12, 2024, at 1:35 p.m. indicated that the resident was incontinent due to catheterization (presence of an indwelling catheter- a thin, flexible tube inserted into the bladder to drain urine from the bladder) and EBP were initiated due to the resident having a dialysis port. A nurse's note, dated September 12, 2024, at 9:49 p.m. indicated that the medical director was notified of the resident's COVID-positive results. A physician's order for Resident 1, dated September 12, 2024, included an order for the resident to be placed on contact and droplet precautions, which included wearing masks (N95), gloves, gowns, and eye shields every shift due to COVID-positive results. A physician's order, dated September 14, 2024, included an order for the resident to receive a therapy pack of 150 milligram (mg) of Nirmatrelvir and 100 mg of Ritonavir two tablets twice daily for five days. Observations during the facility tour on September 17, 2024, at 9:15 a.m. revealed that Resident 1 was in his room lying in bed, and the door to his room was open. There was a red biohazard container in hallway outside of his room and an isolation station was in the hallway outside his room with Personal Protective Equipment (PPE) stocked in it with gowns, surgical masks, and N95 masks. The isolation station did not contain eye shields. Signage on door indicated that the resident was on droplet precautions. Observations on September 17, 2024, at 12:43 p.m. revealed that Nurse Aide 1 exiting Resident 1's room wearing a surgical mask and gloves. Nurse Aide 1 was not wearing a gown or eye shields. While wearing the soiled gloves, she walked to the supply room, got bed sheets, and went back into his room with the same pair of gloves and surgical mask and without a gown or eye shields. Observations on September 17, 2024, at 12:46 p.m. revealed that Nurse Aide 1 and Nurse Aide 2 exited Resident 1's room with surgical masks and gloves on. They were not wearing N95 masks, gowns, or eye shields. They removed their gloves and used hand sanitizer. Interview with Nurse Aide 1 and Nurse Aide 2 at that time confirmed that they should have had gowns on but did not think it was necessary to have N95 masks or eye shields on. Nurse Aide 1 indicated that they only gave the resident his food and had to change his sheets. Nurse Aide 2 indicated that she was unsure what she was supposed to be doing as things were always changing. An admission nurse's note for Resident 2, dated September 10, 2024, at 10:57 a.m. revealed that EBP were initiated due to the resident having a dialysis port. A nurse's note, dated September 14, 2024, at 1:59 p.m. indicated that during day five testing per admission orders, the resident tested positive for COVID. A physician's order for Resident 2, dated September 14, 2024, included an order for the resident to be placed on contact and droplet precautions, which included wearing masks (N95), gloves, gowns, and eye shields every shift for 10 days due to COVID-positive results. Observations during the facility tour on September 17, 2024, at 9:02 a.m. revealed that Resident 2 was in his room in a bed by the window. There was a red biohazard container in hallway outside of his room and an isolation station was in the hallway outside his room with PPE stocked in it, including gowns and N95 masks. The isolation station did not contain protective eye shields. Signage on door indicated that the resident was on droplet precautions. Observations on September 17, 2024, at 9:10 a.m. revealed that Nurse Aide 3 and Nurse Aide 4 exited Resident 2's room with surgical masks and gloves on and no gowns. Interview with Nurse Aide 3 at that time indicated that they would wear full PPE including gowns, N95 mask, and eye shields if they had direct contact with a resident who was positive with COVID. She indicated that they were working with the resident in the other bed by the door who did not have COVID. She indicated that she had just returned after having COVID herself. Nurse aide 4 was present during the interview with Nurse Aide 3 and had no input at the time. Observations on September 17, 2024, at 12:14 p.m. revealed staff in the room giving care to Resident 2 wearing gloves, gowns, surgical masks, and no protective eye shields. Observations at 12:21 p.m. revealed that Nurse Aide 4 and Nurse Aide 5 exited Resident 2's room and took their gowns and gloves off outside the room and disposed of them in the red biohazard container. Observations revealed that as they exited the resident's room, they had surgical masks on and no protective eye shields. Interview with Nurse aide 4 and Nurse Aide 5 at that time confirmed they should have had N95 masks on and eye shields when caring for Resident 2, who was still on droplet precautions for COVID. The N95 masks were available in the isolation station outside of the resident's room, but eye shields were not stocked in the isolation station. Interview with the Assistant Director of Nursing/Infection Preventionist on September 17, 2024, at 2:00 p.m. confirmed that the staff should have been wearing full PPE when caring for Resident 1 and Resident 2, including protective eye shields, N95 masks, gowns, and gloves as per the facility protocol and as per physician's orders. She confirmed that PPE should be accessible for staff when caring for residents positive with COVID and that the isolation stations should be stocked with the appropriate PPE, including protective eye shields. She indicated that staff were educated on COVID precautions and that the outbreak began with a staff member. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated July 24, 2024, revealed that the resident was cognitively intact, required assistance with care needs, had an indwelling catheter, and had diagnoses that included neurogenic bladder (bladder lacks control due to nerve or muscle problems) and quadriplegia (paralysis of both arms and legs). A physician's order for Resident 3, dated December 14, 2023, revealed that the resident had an indwelling catheter related to his diagnosis of neuromuscular dysfunction of bladder and quadriplegia. A physician's order, dated May 15, 2024, included an order for EBP related to his indwelling catheter. Observations on September 17, 2024, at 9:38 a.m. revealed that two staff had transferred Resident 3 from his bed to his chair via the mechanical lift. They had no gloves or gowns on. Nurse Aide 6 was observed handling the indwelling catheter tube ungloved while positioning it on his chair . Interview with Nurse Aide 6 at that time indicated that she would wear gloves and gowns if doing direct care but that was already done. She indicated that all they had to do was transfer the resident out of the bed with the lift and into his chair. Observations revealed there was an isolation station in the resident's room by the sink in his room, but it was empty. Nurse Aide 6 acknowledged that it should be stocked with the appropriate PPE and indicated that she would need to restock it. Interview with the Assistant Director of Nursing/Infection Preventionist on September 17, 2024, at 2:00 p.m. confirmed that the staff should have had gloves and gowns on when transferring Resident 3 and handling his indwelling catheter. She confirmed that PPE should be accessible for staff when caring for residents on EBP and that the isolation stations should be stocked with the appropriate PPE. A quarterly MDS assessment for Resident 5, dated August 9, 2024, revealed that the resident was cognitively impaired, required assistance with care needs, had an indwelling catheter, and a diagnosis that included neurogenic bladder. A physician's order for Resident 5, dated August 2, 2024, included an order for EBP related to his indwelling catheter. A physician's order, dated August 2, 2024, revealed that the resident had an indwelling catheter related to his neuromuscular dysfunction of bladder diagnosis. Observations during the facility tour on September 17, 2024, at 9:56 a.m. revealed that Resident 5 had signage on his door that indicated he was on EBP. There was no isolation station containing PPE on his door or in his room/bathroom. An Annual MDS assessment for Resident 6, dated July 19, 2024, revealed that the resident was cognitively intact, required assistance with care needs, had an indwelling catheter, and a diagnosis that included obstructive uropathy. A physician's order for Resident 6, dated April 5, 2024, revealed that the resident had an indwelling suprapubic catheter (a flexible tube that drains urine from the bladder through the abdomen) related to his diagnosis of neuromuscular dysfunction of bladder. A physician's order, dated May 15, 2024, included an order for EBP related to his indwelling suprapubic catheter. Observations during the facility tour on September 17, 2024, at 10:10 a.m. revealed that Resident 6 had signage on his door that indicated he was on EBP. There was no isolation station containing PPE on his door. There was a bin in his room under his sink, but it was empty. A significant change MDS assessment for Resident 7, dated July 23, 2024, revealed that the resident was cognitively intact, required assistance with care needs, and had a urinary tract infection in the last 30 days. A physician's order for Resident 7, dated September 13, 2024, revealed that the resident was on EBP related to MDRO Colonization. Observations during the facility tour on September 17, 2024, at 10:11 a.m. revealed that Resident 7 had signage on his door that indicated he was on droplet precautions. He indicated that he had COVID, but was clear now and past the stage of needing precautions. There was no isolation station containing PPE on his door or in his room/bathroom. Interview with the Assistant Director of Nursing/Infection Preventionist on September 17, 2024, at 2:00 p.m. confirmed that isolation stations should be accessible for staff when caring for residents on EBP and that the isolation stations should be stocked with the appropriate PPE. She indicated that they were placing the isolation stations with the PPE in the hallways but decided putting them in the resident rooms was more presentable. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies, clinical records, and facility investigative documents, as well as staff interviews, it was determined that the facility failed to ensure that each resident received adequate supervision by failing to ensure that care-planned interventions were in place for one of four residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 21, 2024, indicated that the resident could usually understand, was usually understood, was cognitively intact, and required extensive assistance from staff for daily care. Resident 2's care plan, dated June 14, 2023, revealed that she was to have an extensive assist of two when providing care. A witness statement from Nurse Aide 1, dated March 27, 2024, revealed that she provided incontinence care to Resident 2 by herself around 12:00 a.m A witness statement from Licensed Practical Nurse 2, dated March 27, 2024, revealed that Tylenol was administered to Resident 2 at 1:00 a.m. due to the resident complaining of pain. A witness statement from Nurse Aide 3, dated March 27, 2024, revealed that at around 3:30 a.m. to 4:00 a.m. she asked Resident 2 if she needed incontinence care, and the resident refused to roll due to severe pain. A witness statement from Licensed Practical Nurse 4, dated March 27, 2024, revealed that she observed a bruise to Resident 2's forehead during the 7:30 a.m. medication administration and notified the registered nurse. A nursing note for Resident 2, dated March 27, 2024, revealed that the resident had a raised, bruised area on her forehead; the resident stated she rolled out of bed but was not able to tell staff how she got back into bed; the resident's right hip was swollen; and the resident complained of pain to her right hip. The physician and Director of Nursing were notified. New orders were given for the resident to receive an x-ray, and the Director of Nursing notified the resident's responsible party. A nursing note for Resident 2, dated March 27, 2024, revealed that the physician and responsible party were notified of the x-ray results, and the resident was sent to the emergency room for evaluation. A nursing note for Resident 2, dated March 27, 2024, revealed that the family called and notified the facility that the resident was being admitted to the hospital with a diagnosis of a right hip fracture, and she was scheduled for surgery. Interview with Resident 2 on April 5, 2024, at 10:54 a.m. revealed that she fell out of bed, but when asked if she notified staff, she denied it and stated, It's my little secret. Interview with Licensed Practical Nurse 5 on April 5, 2024, at 10:56 a.m. revealed that if Resident 2 fell out of bed she would be unable to get back into bed on her own. Interview with the Director of Nursing on April 5, 2024, at 11:42 a.m. confirmed that Nurse Aide 1 did provide care to Resident 2 on March 27, 2024, by herself at midnight when she should have had assistance. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(d) Resident Care Policies. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of 31 residents reviewed (Resident 38). Findings include: A facility policy for care planning, dated November 16, 2023, revealed that assessments of residents were ongoing and care plans were revised as information about the residents' conditions change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated August 8, 2023, revealed that the resident was understood and could understand others, had a cognitive impairment, and was dependent on staff for daily care needs. A care plan for Resident 38, updated August 8, 2023, revealed that the resident was receiving a diuretic medication (water pill). Current physician's orders for Resident 38 revealed that the resident was not receiving a diuretic medication. Interview with Director of Nursing on December 8, 2023, at 08:43 a.m. confirmed that Resident 38 was not on diuretics and that the care plan was not updated. 28 Pa. Code 211.11(d) Resident care plans.

Based on clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to ensure that a dialysis emergency kit was at the resident's bedside for one of 32 residents reviewed (Resident 25). The findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated September 5, 2023, indicated that the resident was cognitively intact and required hemodialysis (a process of cleaning the blood of toxins and returning it into the body). Physician's orders, dated September 6, 2023, included an order for the resident to have a dialysis emergency kit containing a tourniquet, sterile gauze, gloves, etc. at the resident's bedside in order to stop bleeding in case the resident's dialysis catheter pulls out or breaks off. Observation of Resident 25 on December 7, 2023, at 9:09 a.m. revealed that she was lying in bed and had a fistula to her left arm. There was no emergency equipment at her bed side. Interview with Licensed Practical Nurse 2 on December 7, 2023, at 9:09 a.m. revealed that if the emergency equipment was in the room, it would be taped on the wall or in the resident's top dresser drawer beside the bed. She confirmed that the equipment was not in place in Residents 25's room and should have been. Interview with the Director of Nursing on December 7, 2023, at 10:09 a.m. confirmed that there should have been a dialysis emergency kit at Resident 25's bedside. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of 32 residents reviewed (Residents 31, 34, 54). Findings include: The facility's policy regarding medication administration, dated November 16, 2023, indicated that staff were to document on the appropriate line of the resident's Medication Administration Record (MAR) that the medication was given. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 31, dated November 8, 2023, revealed that the resident is alert, able to make needs known, and requires assistance with all care. Physician's orders for Resident R31, dated May 12, 2023, included an order for the resident to receive one 5/325 milligrams (mg) tablet of Norco (a controlled narcotic pain medication) every six hours as needed for moderate to severe pain. Resident R31's controlled drug records for September and October 2023 indicated that a dose of Norco was signed out on September 12, 2023, and on October 10, 2023; however, the resident's clinical record, including the MAR, contained no documented evidence that Norco was actually administered to the resident on these dates. Interview with the Director of Nursing on December 7, 2023, at 10:31 a.m. confirmed that there was no documented evidence that doses of Norco that were signed-out by nurses were actually administered to Resident R31 on the above dates. An annual MDS assessment for Resident 34, dated November 3, 2023, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included high blood pressure, heart failure, and arthritis. Physician's orders for Resident 34, dated November 2, 2023, included orders for the resident to receive 50 milligrams of Tramadol (a controlled pain medication) every six hours as needed for pain. A review of the controlled drug record for Resident 34, dated October 2023, indicated that a dose of Tramadol was signed out on October 29, 2023, at 3:00 a.m., 4:00 p.m., and 10:00 p.m. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence that the signed-out tablets of Tramadol were administered to the resident on the above date and times. An interview with the Director of Nursing on December 6, 2023, at 3:07 p.m. confirmed that there was no documented evidence that staff administered the controlled drugs to Resident 34 on the above date and times. The facility's policy regarding discarding and destroying medications, dated November 16, 2023, indicated that the medication is wasted in accordance with federal, state and local waste regulations, as well as the Controlled Substance Act and DEA regulations. The medication disposition must contain a witness signature. A quarterly MDS assessment for Resident 54, dated July 26, 2023, revealed that the resident was cognitively impaired, received pain medication routinely, received an opioid (a controlled pain medication), and had diagnoses that included medically complex conditions. Physician's orders for Resident 54, dated October 12, 2023, included an order for the resident to receive a 75 micrograms (mcg) Fentanyl (a narcotic pain patch) patch to be applied every three days for pain. The Medication Administration Record (MAR) and a controlled drug count record (tracks each dose of a controlled medication) for Resident 54, dated October 2023, revealed that three 25 mcg Fentanyl patches were applied to the resident on October 27, 2023, instead of one 75 mcg Fentanyl patch. One 75 mcg Fentanyl patch was applied to the resident on October 30, 2023. There was no documented evidence that two staff members signed that three 25 mcg Fentanyl patches were destroyed on October 30, 2023. Interview with the Director of Nursing on December 6, 2023, at 8:43 a.m. confirmed that there were not two witness signatures for the destruction of Fentanyl patches October 30, 2023. 28 Pa. Code 211.9(h) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy and clinical records reviews, as well as observations and staff interviews, it was determined that the facility failed to label medications with the date they were opened for one of three bottles in the medication refrigerator. Findings include: The facility's policy on medication labeling and storage, dated November 16, 2023, revealed that multi-dose vials that have been opened or accessed (needle punctured) are to be dated and discarded within 28 days. Observations in the facility's medication room refrigerator on December 7, 2023, at 1:01 p.m. revealed one opened and undated bottle of Tubersol Tuberculin injection for Mantoux TB skin test (to test for tuberculosis). Interview with Registered Nurse 8 on December 7, 2023, at 1:01 p.m. confirmed that the bottle of Tubersol was not dated when it was opened, and that it should have been. Interview with the Director of Nursing on December 7, 2023, at 1:34 p.m. confirmed that the opened vial of Tubersol should have been dated when opened. 28 Pa. Code 211.9(a)(1)(h) Pharmacy services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that resident-centered care plans were developed and implemented for four of 32 residents reviewed (Residents 12, 37, 60, 69). Findings include: A facility policy regarding comprehensive, person-centered care plans, dated December 21, 2022, indicated that the care plan would include measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs and be developed and implemented for each resident. The care plan will identify problem areas and their causes that are meaningful to the resident. The care plan shall be reviewed and updated when there has been a significant change in the resident's condition. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated October 19, 2023, indicated that the resident was severely cognitively impaired, required partial to moderate assistance for care, and had cancer. Physican's orders, dated October 30, 2023, included an order for the resident to be administered 250 milligrams (mg) of Depakote twice a day for seizures. Nursing notes for Resident 12, dated October 30, 2023, revealed that the resident was found on the floor on the right side of his bed and had a 45-second-long seizure with full body convulsions. There was no documented evidence that a care plan was developed to address Resident 12's individual care and treatment needs related to his seizure activity. An interview with the Director of Nursing on December 6, 2023, at 8:36 a.m. confirmed that there was no care plan in place for Resident 12's care and treatment needs related to his seizures, and there should have been. A quarterly MDS assessment for Resident 37, dated September 19, 2023, revealed that the resident was cognitively impaired, required extensive assistance from staff for daily care needs, was receiving oxygen services, and had diagnoses that included high blood pressure and atrial fibrillation (irregular heartbeat). Physician's orders for Resident 37, dated September 12, 2023, included orders for the resident to have oxygen at 0-6 to maintain pulse ox above 92 percent via nasal cannula. There was no documented evidence that a care plan was developed to address Resident 37's individual care and treatment needs related to her use of oxygen. An interview with the Director of Nursing on December 6, 2023, at 8:36 a.m. confirmed that there was no care plan in place for Resident 37's care and treatment needs related to her use of oxygen. A quarterly MDS assessment for Resident 60, dated September 29, 2023, indicated that the resident was severely cognitively impaired, required substantial assistance for care, and had dementia. A care plan for Resident 60, dated April 11, 2023, revealed that the resident had cognitive loss related to dementia. Observations of Resident 60 on December 4, 2023, during the initial tour observed the resident in room [ROOM NUMBER] on A hall and then in room [ROOM NUMBER] on C hall, which is not the resident's assigned room. Observations on December 6, 2023, at 10:10 a.m., revealed that the resident came out of room [ROOM NUMBER] and then went into room [ROOM NUMBER] on A hall. The male resident in room [ROOM NUMBER] asked Resident 60, What are you doing in here honey? At 10:13 a.m., Nurse Aide 1 redirected Resident 60 to leave the room, and confirmed that she has been wondering in and out of rooms. There was no documented evidence that a care plan was developed to address Resident 60's individual care and treatment needs related to her wandering behaviors. An interview with the Director of Nursing on December 7, 2023, at 10:32 a.m. confirmed that there was no care plan in place for Resident 60's care and treatment needs related to her wandering into other residents' rooms, and there should have been. A quarterly MDS assessment for Resident 69, dated November 3, 2023, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnosis that included high blood pressure, heart failure, and urinary stress incontinence. Physician's orders for Resident 69, dated November 23, 2023, included orders for the resident to take 250 milligrams of Ciprofloxacin (an antibiotic for urinary tract infection) two times a day for 14 days . There was no documented evidence that a care plan was developed to address Resident 69's individual care and treatment needs related to her use of antibiotics for a urinary tract infection. An interview with the Director of Nursing on December 6, 2023, at 8:36 a.m. confirmed that there was no care plan in place for Resident 69's care and treatment needs related to her antibiotic use for a urinary tract infection. 28 Pa. Code 211.11(d) Resident care plans. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of personnel files and staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for three of three nurse aides reviewed (Nurse Aides 3, 4, 5). Findings include: A list of nurse aides provided by the facility revealed that based on their months and dates of hire, annual performance evaluations were due during the 2023 calendar year for Nurse Aides 3, 4 and 5. The date of hire for Nurse Aide 3 was March 27, 2017; Nurse Aide 4 was June 15, 2021; and Nurse Aide 5 was June 15, 2021. As of December 7, 2023, there was no documented evidence that annual performance evaluations were completed for 2023 as required for Nurse Aides 3, 4 or 5. Interview with the Nursing Home Administrator on December 7, 2023, at 2:33 p.m. confirmed that annual performance evaluations were not completed as required for Nurse Aides 3, 4 and 5. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.20(a)(c) Staff development.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation for two of seven residents reviewed (Residents 1, 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 2, 2023, revealed that the resident was cognitively impaired, required extensive assistance with daily care activities, including bed mobility, was dependent for transfers, could not walk, was incontinent of bowel and bladder, had a Stage 3 pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle is not exposed), and had a Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle). The resident's care plan, dated September 19, 2022, included that the resident had pressure ulcers, and treatments were to be completed as ordered by the physician. Physician's orders for Resident 1, dated June 2, 2023, included an order for 0.25 percent acetic acid (inhibits bacterial growth and promotes wound healing) irrigation solution to be applied to the sacrum (area at the base of the spine) topically every day and evening shift for a pressure ulcer. Staff were to cleanse the area with acetic acid, pack the area to the sacrum with acetic acid-soaked gauze, and cover with a dressing every day and evening shift. A wound consultation for Resident 1, dated August 11, 2023, revealed that the resident had a Stage 4 pressure ulcer to her sacrum that measured 4.0 x 3.5 x 1.0 centimeters (cm) and had undermining (breakdown under the skin) from 9 o'clock to 3 o'clock, 2.0 cm. The plan was to cleanse the sacrum wound with 1 percent acetic acid, apply acetic acid-soaked gauze to the base of the wound, and covered with gauze twice a day due to increased undermining. Resident 1's Treatment Administration Record (TAR) for August 2023 revealed that the 0.25 percent acetic acid was applied to the resident's sacral wound every day and evening shift. There was no documented evidence that 1 percent acetic acid was started following the recommendations of the wound clinic on August 11, 2023. Interview with the Director of Clinical Operations on August 28, 2023, at 12:50 p.m. confirmed that staff did not follow through and obtain physician's orders for the 1 percent acetic acid treatment to the sacral wound that was recommended by the wound consultant. An admission MDS for Resident 2, dated June 13, 2023, revealed that the resident was able to understand others and was usually able to make herself understood, required extensive assistance from staff for personal care needs, and had diagnoses that included the presence of a Stage 3 pressure ulcer and a need for palliative care (focuses on providing relief from pain and other symptoms of a serious illness). Physician's orders for Resident 2, dated July 20, 2023, included an order for the resident to receive Santyl (medicine that removes dead tissue from wounds so they can start to heal) topically to her coccyx (area at the very bottom part of the spine) every day shift for wound healing. A care plan for Resident 2, dated June 28, 2023, revealed that the resident had actual skin breakdown related to a terminal ulcer on her coccyx due to immobility, with an intervention to administer treatments per physician's orders. Review of a wound consultation for Resident 2, dated August 11, 2023, revealed that the resident had a terminal wound to her coccyx and included orders to discontinue using Santyl on the resident's coccyx. Review of the TAR for Resident 2, dated July and August 2023, revealed that Santyl was applied to the resident's coccyx daily from July 20, 2023, through August 28, 2023. Interview with the Director of Clinical Operations on August 28, 2023, at 12:49 p.m. confirmed that staff did not follow through and obtain physician's orders to discontinue Santyl to Resident 2's coccyx as recommended by the wound consultant on August 11, 2023. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to implement its abuse prohibition policies regarding verifying new employees' standing with the State Board of Nursing for two of five new employees reviewed (Registered Nurse 5, Licensed Practical Nurse 6). Findings include: The facility's policy regarding abuse prevention and prohibition, dated February 4, 2022, indicated that the facility would conduct a license verification prior to employment. The personnel file for Registered Nurse 5 revealed that she was hired on November 28, 2022; however, there was no documented evidence that her professional license was verified with the State Board of Nursing prior to being hired. The personnel file for Licensed Practical Nurse 6 revealed that she was hired on December 5, 2022; however, there was no documented evidence that her professional license was verified with the State Board of Nursing prior to being hired. Interview with the Human Resource Director on January 18, 2023, at 2:38 p.m. confirmed that Registered Nurse 5's licensure verification and Licensed Practical Nurse 6's licensure verification should have been completed prior to employment. 28 Pa. Code 201.18(e)(1) Management.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate quarterly Minimum Data Set assessments for one of 27 residents reviewed (Resident 59). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, revealed that Section O0100E (tracheostomy care - care of a surgical incision in the neck that creates an opening into the windpipe) was to be checked if the resident received tracheostomy care while a resident within the last 14 days. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 59, dated December 20, 2022, revealed that the resident was cognitively intact, required limited assist with daily care needs, and had diagnosis that included chronic respiratory failure and tracheostomy. Nursing notes for Resident 59 dated December 14, 2022, at 9:44 p.m. and December 19, 2022, at 2:08 p.m. revealed that that resident had a tracheostomy in place. An interview with the Corporate Director of Clinical Affairs on January 18, 2023, at 4:10 p.m. confirmed that the MDS for Resident 59, completed on December 20, 2022, should have reflected that tracheostomy care was provided. However, there was no documented evidence that tracheostomy care was provided, so there was no evidence that he required this care when the MDS was completed. She confirmed that there should have been documentation of tracheostomy care on the clinical record. An interview with the Director of Nursing on January 19, 2023, at 8:16 a.m. revealed that there were no physician's orders obtained to provide tracheostomy care for Resident 59 during the 14-day look-back period; however, tracheostomy care was being completed by nursing staff and tracheostomy care should have been identified on the MDS. 28 Pa. Code 211.5(f) Clinical records.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for one of 27 residents reviewed (Resident 25) and that the facility failed to obtain a physician's order for an invasive procedure to collect a specimen for a laboratory test for one of 27 residents reviewed (Resident 34). Findings include: The facility's policy regarding medication administration, dated February 4, 2022, revealed that medications are administered in accordance with the written orders of the attending physician, and that the individual who administers the medication dose should record the administration on the resident's medication administration record (MAR) directly after the medication is given. A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated January 9, 2023, revealed that the resident was cognitively intact, needed extensive assistance for daily care needs, and had an indwelling catheter. Physician's orders for Resident 25, dated December 21, 2022, included an order for the resident to receive 2 grams of Ceftriaxone (an antibiotic) once a day for seven days. A review of Resident 25's October 2022 MAR revealed no documented evidence that a dose of Ceftriaxone was administered on October 23, 2022; October 25, 2022; or October 28, 2022, as ordered by the physician. An interview with the Director of Nursing on January 19, 2023, at 1:28 p.m. confirmed that there was no documented evidence that Resident 25 received the ordered doses of Ceftriaxone on the above identified dates. An annual MDS assessment for Resident 34, dated November 15, 2022, revealed that the resident was cognitively intact and required extensive assist with daily care needs. A nursing note for Resident 34, dated December 30, 2022, at 2:44 a.m. revealed that a urine specimen was collected via a straight catheterization procedure (insertion of a plastic tube into the bladder to obtain urine). There was no documented evidence that staff obtained a physician's order to collect the urine specimens via straight catheterization for Resident 34. An interview with the Director of Nursing on January 19, 2023, at 11:16 a.m. confirmed that there was a standing order for all urine specimens to be collected via a straight catheterization procedure, but was not specific to Resident 34. The Director of Nursing stated that she thought a facility-wide order for straight catheterizations for urine specimens was acceptable. There was no evidence of a standing order for straight catherization in Resident 34's medical record. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcer care/prevention treatments were provided as ordered for one of 27 residents reviewed (Resident 25). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated January 9, 2023, revealed that the resident was cognitively intact and needed extensive assistance for daily care needs. A note by the wound care consultant on November 7, 2022, following a visit to the facility for Resident 25, revealed that the resident had unstageable (unable to determine the extent of damage) pressure ulcers (skin impairment caused by pressure) to his right heel, left heel, right gluteus (buttocks), left sacrum (lower back area), and left coccyx (tailbone). A recommendation was made for the resident have bilateral lower extremity arterial and venous doppler studies (a noninvasive test that is used to estimate the blood flow through your blood vessels) done. There was no documented evidence in the clinical record that doppler studies were offered, scheduled, or performed on Resident 25 as recommended. An interview with the Director of Nursing on January 19, 2023, at 1:32 p.m. revealed that she had interviewed the wound nurse, who reported that Resident 25 was offered the doppler studies but refused them. The Director of Nursing also revealed that she had interviewed Resident 25. He cannot remember if he was offered the doppler studies and the Director of Nursing stated that there should have been documentation in the resident's medical record if he refused the doppler studies and there was none. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for an indwelling urinary catheter for one of 27 residents reviewed (Resident 3). Findings include: The facility's policy for insertion of a indwelling urinary catheter, dated February 2, 2022, indicated that staff should verify that there is a physician's order for the procedure. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated January 6, 2023, revealed that the resident was rarely/never understood, could rarely/never understand, required extensive assistance from staff for his daily care tasks, and had an indwelling urinary catheter (a tube inserted through the lower abdominal wall into the bladder to drain urine). Physician's orders for Resident 3, dated January 18, 2023, included an order for an indwelling urinary catheter, size 16 French with a 30 cc balloon. A nurse's note dated January 14, 2023, indicated that Resident 3's catheter was changed due to leakage and that a size 18 French catheter was inserted. There was no documented evidence that an order was obtained for the 18 French catheter. Interview with the Director of Nursing on January 18, 2023, at 15:36 p.m. confirmed that there was no documented evidence of a physician's order for Resident 3's 18 French catheter. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on a review of clinical records, as well as staff interviews it was determined that the facility failed to maintain clinical records that were complete and accurate for two of the 27 residents reviewed (Residents 28, 36). Findings include: A quarterly Minimum Data Set (MDS) Assessment (a mandated assessment of a resident's abilities and care needs) for Resident 28, dated February 10, 2022, indicated that she was confused, and that she required extensive assistance of one for bed mobility, limited assistance of one for transfers, and ambulation in the room. A nursing note for Resident 28, dated September 22, 2022, indicated that it was a post event note related to a fall on September 21, 2022. The facility's investigation, dated September 21, 2022, indicated that she had an unwitnessed fall. She was found on the floor on the D nursing wing and had a hematoma on the right side of her head. There was no documented evidence in Resident 28's clinical record of the incident that occurred on September 21, 2022. Interview with the Director of Nursing on January 19, 2023, at 12:15 p.m. confirmed that the actual incident was not documented in the clinical record and that it should have been. An annual MDS for Resident 36, dated December 1, 2022, indicated that she could understand, is understood, required extensive assistance of two for bed mobility, and total dependence for transfers. A nursing note for Resident 36, dated January 13, 2023, revealed that the resident was re-admitted to the facility with a diagnosis of pneumonia (inflammation of the lung caused by and infection). Physician's orders for the resident, dated January 13, 2023, included an order for the resident to receive 1 gram of Meropenem (antibiotic) Solution intravenously (IV - directly into a vein) two times a day for five days. Resident 36's Medication Administration Records (MAR's) for January 2023 revealed that the resident received IV Meropenem two times per day on January 14, 16 and 18. However there was no documented evidence that Resident 36 received IV Meropenem two times a day on January 15 and 17, 2023, as ordered. Interview with Director of Nursing on January 18, 2023, at 3:36 p.m. confirmed that Registered Nurse 3 did give the Meropenem two times each day on January 15 and 17, 2023, but forgot to document that she gave it. Registered Nurse 3 was on the schedule during the survey period and confirmed that she did not document that she gave the Meropenem. 28 Pa. Code 211.5(f) Clinical records.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending February 15, 2022, and a complaint survey ending September 29, 2022, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending January 19, 2023, identified repeated deficiencies related to a failure to complete accurate Minimum Data Sets and failure to provide quality of care services. The facility's plan of correction for a deficiency regarding developing comprehensive care plans, cited during the survey ending February 15, 2022, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure Minimum Data Sets were completed accurately. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending September 29, 2022, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care services. Refer to F641, F684. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed while providing care for one of 27 residents reviewed (Resident 42). Findings include: The facility's eye drop administration policy, dated February 4, 2022, indicated that staff were to wear gloves when administering eye drops. Observations during medication administration on January 18, 2023, at 8:25 a.m. revealed that Licensed Practical Nurse 8 administered eye drops to Resident 42 with her bare hands. Interview with Licensed Practical Nurse 8 on January 18, 2023, at 3:03 p.m., revealed that she should have worn gloves during medication pass while administering eye drops and she did not. Interview with the Director of Nursing on January 18, 2023, at 3:36 p.m. revealed that Licensed Practical Nurse 8 should have worn gloves while administering eye drops. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, established infection control standards from the Centers for Medicare & Medicaid Services and the Pennsylvania Department of Health, and clinical records, as well as staff interviews, it was determined that the facility failed to conduct testing for a resident who exhibited signs and symptoms of COVID-19 for one of 27 residents reviewed (Resident 30). Findings include: The Centers for Medicare and Medicaid Services (CMS) memo QSO-20-38-NH, regarding COVID-19 testing requirements in long-term care (LTC) facilities, dated August 26, 2020, and revised September 23, 2022, revealed that facilities were required to test residents for COVID-19 based on parameters set forth by the Secretary of Health and Human Services, including testing any identified individual with symptoms consistent with COVID-19, or with known or suspected exposure to COVID-19. Pennsylvania Department of Health Alert Network (PAHAN) - 663 regarding Interim Infection Prevention and Control, Recommendations for Healthcare Settings during the COVID-19 Pandemic, dated October 4, 2022, revealed that anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test as soon as possible. A facility policy for Coronavirus Disease (COVID-19) - Testing Residents, dated February 4, 2022, included that any resident, regardless of vaccination status, with even mild symptoms of COVID-19 should receive a viral test as soon as possible. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 30, dated December 16, 2022, revealed that the resident was able to understand others and make himself understood, and required extensive assist of two people for daily care needs. A nurse's note for Resident 30, dated December 19, 2022, revealed that the resident had a sore throat and a hoarse voice. A nurse's note, dated December 30, 2022, revealed that the resident had an increase in mucous secretions, and a nurse's note, dated December 31, 2022, revealed the resident was coughing up yellow secretions and had scattered rhonchi (abnormal lung sounds) throughout his lungs. There was no documented evidence that Resident 30 was tested for COVID-19 when he exhibited any of the symptoms mentioned. An interview with the Director of Nursing on January 19, 2023, at 2:14 p.m. revealed that Resident 30 should have been tested for COVID-19 because of his symptoms, and although she believes it was done, there was no documented evidence of COVID-19 testing being done on the resident and there should have been. 28 Pa. Code 211.5(f) Clinical records.

Based on a review of facility policies and employee education records, as well as staff interviews, it was determined that the facility failed to ensure that nurse aides completed the required annual education for one of three nurse aides reviewed (Nurse Aide 7). Findings include: The facility's policy for abuse prevention, dated Feburary 4, 2022, indicated that staff were required to have annual trainings. Review of the employee education file for Nurse Aide 7 revealed that there was no documented evidence of annual dementia management training or training regarding cognitive impairments. Interview with the Director of Nursing on January 18, 2023, at 3:13 p.m. confirmed that there was no documented evidence that Nurse Aide 7 completed the annual training as required. 28 Pa. Code 201.18 (b)(3)(e)(1) Management. 28 Pa. Code 201.19 Personnel policies and procedures.

Based on review of the facility's policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an intravenous (IV) catheters (a thin tube inserted into a vein for the administration of fluids and/or medications) were flushed as ordered for two of 27 residents reviewed (Residents 25, 36). Findings include: The facility's policy for flushing IV catheters, dated February 4, 2022, indicated that the IV catheter was to be flushed before and after it was used to administer medication and that the procedure should be documented in the resident's treatment administration record (TAR). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated January 9, 2023, revealed that the resident was cognitively intact and required extensive assistance for daily care needs. Physician's orders for Resident 25, dated December 21, 2022, included an order for the resident to receive 2 grams of Ceftriaxone (an antibiotic) daily for seven days through his IV. Physician's orders for Resident 25, dated December 22, 2022, included an order for the resident's IV catheter to be flushed every shift to maintain patency and before and after each medication administration. A review of Resident 25's medication administration record (MAR) and treatment administration record (TAR) for October 2022 revealed no documented evidence that the resident's IV was being flushed before and after each medication administration, and there was no documented evidence that the IV catheter was flushed to maintain patency on October 23, 2022, on day shift; October 24, 2022, on evening shift; October 24, 2022, on night shift; October 25, 2022, on day shift; and October 28, 2022, on day shift. An interview with the Director of Nursing on January 19, 2023, at 1:28 p.m. confirmed that there was no documented evidence that Residents 25's IV catheter was flushed before and after it was used to administer medication and to maintain patency on the dates identified above and that it it should have been. A nursing note for Resident 36, dated January 13, 2023, revealed that the resident was re-admitted to the facility with a diagnosis of pneumonia (inflammation of the lung caused by and infection). Physician's orders for the resident, dated January 13, 2023, included an order for the resident to receive 1 gram of Meropenem (antibiotic) intravenously (IV - directly into a vein) two times a day for five days. Review of Resident 36's Medication Administration Records (MAR's) for January 2023 revealed that the resident received IV Meropenem two times a day; however, there was no documented evidence that staff flushed the resident's IV catheter with normal saline solution before and after the administration of Meropenem per the facility's policy. Interview with the Director of Nursing on January 18, 2023, at 3:36 p.m. confirmed that Resident 36's IV should have been flushed with normal saline before and after the administration of Meropenem. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were obtained to provide tracheostomy care (care of a surgical incision in the neck that creates an opening into the windpipe) for one of 27 residents reviewed (Resident 59). Findings include: The facility's policy for tracheostomy care, dated February 4, 2022, indicated that tracheostomy care should be provided as often as needed, at least once daily for old, established tracheostomies, and at least every 8 hours for residents with unhealed tracheostomies. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 59, dated December 20, 2022, revealed that the resident was cognitively intact, required limited assistance with daily care needs, and had diagnoses that included chronic respiratory failure and tracheostomy. A respiratory impairment care plan for Resident 59, dated December 14, 2022, included that he had or was at risk for respiratory impairment related to a tracheostomy and that tracheostomy care should be provided per facility protocol. A review of December 2022 physician's orders for Resident 59 revealed that there were no orders for the resident to receive tracheostomy care from his admission date of December 14, 2022, until December 29, 2022. Nursing notes for Resident 59, dated December 14, 2022, at 9:44 p.m. and December 19, 2022, at 2:08 p.m. revealed that that resident had a tracheostomy in place. A review of nurses' notes, medication administration records (MAR), and treatment administration records (TAR) for December 2022 revealed that there was no documented evidence of tracheostomy care being provided between December 14, 2022, and December 29, 2022. An interview with the Director of Nursing on January 19, 2023, at 8:16 a.m. confirmed that no orders were obtained to provide tracheostomy care to Resident 59 when he was admitted and should have been, and that there should have been documentation of the tracheostomy care provided in the resident's medical record. She further indicated that the tracheostomy care was being provided even though it was not documented. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.