Does WILLOWS OF PRESBYTERIAN SENIOR have any serious inspection findings?

Yes, WILLOWS OF PRESBYTERIAN SENIOR has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 48 total deficiencies from recent inspections.

What are the staffing levels at WILLOWS OF PRESBYTERIAN SENIOR?

WILLOWS OF PRESBYTERIAN SENIOR has a four-star staffing rating from CMS with 0.73 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is WILLOWS OF PRESBYTERIAN SENIOR located?

WILLOWS OF PRESBYTERIAN SENIOR is located in OAKMONT, PA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does WILLOWS OF PRESBYTERIAN SENIOR have?

WILLOWS OF PRESBYTERIAN SENIOR has 193 certified beds.

Who owns WILLOWS OF PRESBYTERIAN SENIOR?

WILLOWS OF PRESBYTERIAN SENIOR is a non profit - corporation facility and operates independently (not part of a chain).

How does WILLOWS OF PRESBYTERIAN SENIOR compare to other nursing homes?

WILLOWS OF PRESBYTERIAN SENIOR has a 1-star overall rating, which is below average compared to other nursing homes in PA. Families should carefully review inspection findings and consider alternatives.

WILLOWS OF PRESBYTERIAN SENIOR

Name: WILLOWS OF PRESBYTERIAN SENIOR
Address: 1215 HULTON ROAD, OAKMONT, PA, 15139, US
Telephone: (412) 828-5600
Rating: 1.0

1215 HULTON ROAD, OAKMONT, PA 15139 · (412) 828-5600

Non profit - Corporation 193 Beds Independent Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

21/100

#650 of 653 in PA

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Last Inspection: November 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Willows of Presbyterian Senior has received a Trust Grade of F, indicating significant concerns about the facility's operations and care quality. It ranks #650 out of 653 facilities in Pennsylvania, placing it in the bottom half, and #51 out of 52 in Allegheny County, meaning there is only one local option considered worse. On a positive note, the facility's trend shows improvement, with issues decreasing from 17 in 2024 to 4 in 2025. Staffing is a relative strength, rated 4 out of 5 stars, with a turnover of 50%, which is close to the state average. However, the facility faces serious concerns, including an incident where a resident was able to leave unsupervised, and another where a lack of assistance led to a knee fracture, highlighting the need for better supervision and care protocols. Overall, while there are some strengths in staffing and a positive trend, the facility has serious weaknesses that families should consider.

Trust Score: F
In Pennsylvania: #650/653
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 50% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $11,200 in fines. Higher than 62% of Pennsylvania facilities. Some compliance issues.
Skilled Nurses: Each resident gets 43 minutes of Registered Nurse (RN) attention daily — more than average for Pennsylvania. RNs are trained to catch health problems early.
Violations: 48 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★★☆

4.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 17 issues

2025: 4 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
4-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in staffing levels, quality measures, fire safety.

The Bad

1-Star Overall Rating

Below Pennsylvania average (3.0)

Significant quality concerns identified by CMS

Staff Turnover: 50%

Near Pennsylvania avg (46%)

Higher turnover may affect care consistency

Federal Fines: $11,200

Below median ($33,413)

Minor penalties assessed

The Ugly 48 deficiencies on record

1 life-threatening 1 actual harm

May 2025 3 deficiencies 1 IJ

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). This failure created an immediate jeopardy situation for one of 35 residents (Resident R1) identified as high risk for wandering. Findings include: Review of the facility policy Elopement Process dated August 2024, indicated an elopement assessment is completed upon admission, quarterly, annually, and if a resident actively attempts to elope. If they score a one or above on the elopement risk assessment an elopement device (alarm to alert staff of a resident going beyond a safe area), should be placed. Review of the facility policy Skilled Nursing- Elopement dated August 2024, indicated staff shall investigate and report all cases of missing residents. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. Review of the admission Record indicated Resident R1 was admitted to the facility on [DATE], with the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), atrial fibrillation (irregular heart rhythm), and history of falling. Review of the clinical admission V-19 form dated 5/10/25, at 10:17 p.m. indicated level of cognitive impairment as mild impairment (some confusion). Review of Elopement Evaluation Form dated 5/10/25, at 10:42 p.m. indicated that Resident R1 had an elopement score of zero. Not at risk. Review of Resident R1's progress note 5/12/25, at 3:09 p.m. indicated resident up ambulating (walking) with walker going into other resident rooms. Opening stairwell door. Redirected multiple times. EPD (elopement protection device) placed for safety. Review of Elopement Evaluation Form dated 5/13/25, at 11:08 a.m. indicated resident wanders aimlessly or non-goal directed: Yes. Wandering behavior likely to affect the safety or well-being of self/others: Yes. Wandering behavior likely to affect the privacy of others: Yes. Elopement score 5. Review of physician orders dated 5/13/25, indicated wander guard (EPD) check function every day and placement every shift. Review of Resident R1's care plan dated 5/13/25, indicated resident is an elopement risk/wanderer. EPD applied to left upper extremity. Disoriented to place, impaired safety awareness, wanders aimlessly, significantly intrudes on the privacy or activities of others. Review of Resident R1's progress notes indicated the following: -5/13/25, at 8:32 p.m. thinking orientation: Person. Mental status: pleasant. Smiling delusions (misconceptions or beliefs that are firmly held, contrary to reality) Wandering. Ambulates with front wheeled walker and assist of one. Assist of one for all activities of daily living. Wanders aimlessly, exit seeking at times, in other resident's rooms. EPD in place. -5/14/25, at 9:36 a.m. thinking orientation: Person. Mental status: pleasant smiling delusions wandering. Wanders aimlessly, exit seeking at times, in other resident's rooms. EPD in place. -5/15/25, at 9:34 a.m. Thinking orientation: Person. Mental status: pleasant smiling delusions wandering. Wanders aimlessly, exit seeking at times, in other resident's rooms. EPD in place. -5/15/25, at 7:10 p.m. called to front lobby by Licensed Practical Nurse (LPN) Employee E1 who reports Resident R1 was found in parking lot walking with wheeled walker. When resident was found, EPD alarm was going off and the front door was pushed open. Resident was assessed, no injuries apparent. Weather at the time of occurrence was 72 degrees and sunny. Resident had no complaints of pain or discomfort. Appeared at baseline. On Call supervisor notified, physician ordered immediate transfer of resident to the fourth-floor dementia unit (a secure unit). -5/15/25, at 9:59 p.m. resident was seen in the parking lot of facility by a staff member about 7:00 p.m. with her front wheeled walker. She was redirected into the building. Elopement device intact and active at the time. Resident transferred to the lock down unit afterwards for safety. Resident's Son notified. Review of facility provided documentation dated 5/15/25, indicated Resident R1 was found in the front parking lot with her walker. Upon investigation the resident had an EPD on. The front entrance sliding doors where she exited were alarming and ajar as resident forced them open and off the hinges. The community's EPD system prevents the sliding doors from opening if the alarm sounds, but as they are also fire doors, they are able to be pushed open with force in case of emergencies. Entrance doors were pushed open and off hinges which showed this occurred. Resident was last seen by NA Employee E2 at 6:45 p.m. Further review of Resident R1's care plan dated 5/16/25, indicated the resident has impaired cognitive dementia, low safety awareness, has attempted to elope, wanders, need for locked memory unit. Review of Nurse Aide (NA) Employee E2's undated witness statement indicated he took Resident R1 back to her room at 6:45 p.m. while cleaning up after dinner. Placed her call bell, pinned to her shirt, in her room watching TV. Then, NA Employee E2 went on to care for other residents. Review of LPN Employee E1's witness statement dated 5/16/25, at 8:49 a.m. indicated at approximately 7:10 p.m. the front door was alarming. She turned off the alarm and noticed one of the sliding doors was pushed open. She looked outside and observed a resident walking in the parking lot and noticed an EPD on resident's walker. She redirected resident back inside the facility. When asked her name, the resident indicated an incorrect last name. Supervisor notified of both lobby and patio sliding doors being pushed open. Telephonic interview on 5/22/25, at 11:10 a.m. LPN Employee E1 indicated she was coming down off the elevator, heading towards the lobby. When she turned the corner, she could hear the alarm and proceeded to the front door where she saw Resident R1 outside with a EPD device. She indicated she did not hear the alarm until she turned the corner. When asked if she could hear the alarm at the nursing unit, she indicated no. Interview on 5/22/25, at 11:30 a.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision for one resident resulting in elopement and the failure created an immediate jeopardy situation for one of 35 residents (Resident R1) identified as high risk for wandering. On 5/22/25, at 11:40 a.m., the Nursing Home Administrator was made aware that Immediate Jeopardy (IJ) existed and was provided the IJ Template at that time and a corrective action plan was requested. On 5/22/25, at 3:40 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: Resident R1 was moved immediately to the fourth-floor secured neighborhood after incident occurred on 5/15/25. Resident R1 was assessed for any injuries or psychosocial effects from incident, there were none. Physician and family were notified, care plan was reviewed and person-centered interventions were put into place. Administrator and Director of Nursing (DON) met with family the following day to review plan of care and interventions in place to reduce likelihood of reoccurrence. Residents: All residents in the facility will be assessed by the nursing team for elopement risk using the elopement evaluation tool within the electronic health record by 5/23/25. After all residents are assessed for elopement risk, their care plans will be audited by the nursing team or designee to ensure measurable, person-centered goals and interventions are implemented to prevent residents from eloping by 5/23/25. Root cause of elopement - due to team's lack of supervision, Resident R1 was able to elope outside of front entrance. On 5/16/25, vendor who oversees EPD system came in to ensure system functioned appropriately. Vendor installed four kiosks (One iPad kiosk in the neighborhood and three larger screens mounted on wall in each hallway) on each neighborhood that will audibly alarm in the event that a resident with an EPD is within range. This range was also expanded at this time to alert much earlier before the resident can get to the front entrance. Previously, this did not exist, and the audible alarm would be heard at the front of the building only. Moving forward, kiosks on each neighborhood were changed to ensure that they will alarm in the event that a resident with an EPD device gets in range of the front entrances and exits. System Correction: For any resident exhibiting new wandering behaviors, they will be placed on 15-minute checks by nursing team or designee. This will be documented within the electronic health record by the nursing team by 5/23/25. Physicians will be notified of their residents who are at wandering/elopement risk to collaborate for further interventions by 5/23/25. Administration will review and update policies to identify residents who are at risk for eloping by 5/23/25. A system check was completed on 5/21/25, by maintenance and administration to ensure entrances and exits alarms are functioning as intended. Vendor was contacted to install delayed egress feature on remaining stairwell doors. Monitoring: Whole house staff will be educated by the DON/designee on elopement risk and assessments, person-centered care plans, and supervision of residents before the start of their next shift. Ongoing audits will be completed to ensure residents are appropriately assessed for elopement risk, placed on proper safety checks, and person-centered care plan for elopement is implemented. This will be audited daily by DON/designee for seven days a week for two weeks, five days a week for two weeks and three days a week for two weeks. This incident will also be brought to Quality Assurance Performance Improvement meeting to review and prevent further incidents of this nature. Review of facility's Corrective Action Plan was verified and completed on 5/23/25, at 10:58 a.m. as follows: -Resident R1 was moved to the Fourth-floor secured neighborhood after elopement 5/15/25. -Resident R1 was assessed for injury and psychosocial effects with no new findings. -Physician and family were notified. -Care plan reviewed and person-centered interventions were put into place. Administrator and DON met with son to review the plan of care and interventions to reduce likelihood of recurrence. -All residents, 172 of 172, were re-assessed for elopement using the Elopement Evaluation within the electronic health record. Seven new wandering behavior residents were identified through this process. -Care plans for 172 of 172 residents were audited for measurable person-centered goals, and interventions were implemented to prevent residents from eloping. -Root cause of elopement was due to the team's lack of supervision. -Wander guard system was checked by the vendor to ensure functionality. Vendor installed four kiosks (one iPad in the neighborhood and three larger screens mounted on the wall in each hallway) that will audibly alarm in the event that a resident with a wanderguard was within range of the front entrance. -Prior to this installation, the audible alarm would only be heard if staff were in the front lobby. -All wandering/exit seeking residents' providers were updated 5/22/25, with a list of their respective residents who have been identified as wanders to ensure their collaboration is current. -Residents exhibiting new wandering behaviors will be placed on 15-minute checks by nursing team, moving forward. -New behaviors will be documented in the electronic health record by nursing upon discovery. -Physicians will be notified for further collaboration upon discovery. -The Administrator reviewed and updated the policy to identify residents who are at risk for elopement on 5/22/25, to include adequate supervision will be provided to help prevent accidents or elopements. -Five of five wandering exit/seeking behavior residents were care planned with person centered specific interventions on the Hickory Haven unit. -Nine of nine wandering exit/seeking behavior residents were care planned with person centered specific interventions on the Cedar Heights unit. 28 of 28 wandering exit/seeking behavior residents were care planned with person centered specific interventions on the [NAME] Gardens unit. Seven new residents identified as wandering exit/seeking behaviors through this process. Total of 42 of 42 wandering exit/seeking behavior residents had care plans reviewed. 289 of 298 signatures of all facility staff receiving and understanding education. 88 of all facility staff in person interviews verified receiving and understanding education on elopement and exit seeking behaviors. The Nursing Home Administrator was informed the IJ was lifted on 5/23/25, at 10:58 a.m. Exit interview on 5/23/25, at 11:30 a.m. information was disseminated to the Nursing Home Administrator and the Director of Nursing that the facility failed to make certain each resident received adequate supervision and person-centered care plan interventions that resulted in an elopement. This failure created an immediate jeopardy situation for one of 35 residents (Resident R1) identified as high risk for wandering. 28 Pa. Code 201.14 Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29 Responsibility of Licensee. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 28 Pa. Code 211.10(d) Resident care policies.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on a review of facility policies, documents and staff interviews it was determined that the facility failed to report to the State agency an allegation of misappropriation of resident property as required. (Allegation of misappropriation of resident property). Findings include: A review of facility Skilled Nursing - Abuse policy dated 8/24, revealed that the purpose of the policy is to comply with the seven step approach to abuse and neglect detection and prevention. Abuse is defined to include misappropriation of resident property. Step seven of the approach includes reporting the allegation to the proper agencies. During a review of facility documents submitted to the state agency it was revealed that the facility failed to notify the state agency of allegations of facility staff improperly destroying medications no longer prescribed for the resident as required. During a staff interview on 5/21/25 at 9:00 am the Nursing Home Administrator and Director of Nursing revealed that they were aware of allegations of staff members inappropriately destroying resident medications. The facility began an investigation into the allegation and developed new procedures for the destruction of medications no longer prescribed for the resident but failed to report the investigation to the state agency. During a staff interview on 5/21/25, at 9:00 am the Director of Nursing confirmed that the facility failed to notify the state agency of allegations and an investigation of the allegation for improper destruction of resident medications (misappropriation of resident property) as required. Pa Code: 201.14(a)(c) Responsibility of licensee Pa Code 201.20(b) Staff development

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to make certain exit seeking/wandering residents had a person-centered care plan individualized to each specific resident's needs for eight of 35 residents identified as high risk for wandering/elopement (Residents R1, R2, R3, R4, R5, R6, R7, and R8). Findings included: Review of the facility policy Skilled Nursing-Comprehensive Care Plans dated August 2024, indicated a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change. Review of the facility Elopement Process dated August 2024, indicated an elopement device should be placed if the resident scores a one or above on the elopement evaluation and are an elopement risk. Review of the admission Record indicated Resident R1 was admitted to the facility on [DATE], with the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), atrial fibrillation (irregular heart rhythm), and history of falling. Review of Resident R1's Elopement Evaluation Form dated 5/13/25, at 11:08 a.m. indicated resident wanders aimlessly or non-goal directed: Yes. Is the Resident's wandering behavior likely to affect the safety or well-being of self/others: Yes. Wandering behavior likely to affect the privacy of others: Yes. Elopement score of five. Review of the admission Record indicated Resident R2 was admitted to the facility on [DATE], with the diagnoses of dementia, repeated falls, and depression. Review of Resident R2's Elopement Evaluation Form dated 5/20/25, indicated resident wanders aimlessly or non-goal directed: Yes. Wandering behavior likely to affect the privacy of others: Yes. Elopement score of two. Review of the admission Record indicated Resident R3 was admitted to the facility on [DATE], with diagnoses of dementia, high blood pressure, and insomnia (a sleep disorder where individuals experience difficulty falling asleep, staying asleep or both, leading to daytime impairment). Review of Resident R3's Minimum Data Set (MDS- a periodic assessment of care needs) dated 5/10/25, indicated the diagnoses remain current. Review of Resident R3's Elopement Evaluation Form dated 4/22/25, indicated Does the resident have a history of elopement or an attempted elopement while at home: Yes. Does the resident have a history of elopement or attempted leaving the facility without informing staff: Yes. Does the resident wander: Yes. Elopement score of three. Review of the admission Record indicated Resident R4 was admitted to the facility on [DATE], with diagnoses of high blood pressure, renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R4's MDS dated [DATE], indicated the diagnoses remain current. Review of Resident R4's Elopement Evaluation Form dated 4/1/25, indicated Does the resident have a history of elopement or an attempted elopement while at home: Yes. Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: Yes. Elopement score of two. Review of the admission Record indicated Resident R5 was admitted to the facility on [DATE], with diagnoses of anemia (the blood doesn't have enough healthy red blood cells), hyperlipidemia (high levels of fat in the blood), and depression. Review of Resident R5's MDS dated [DATE], indicated the diagnoses remain current. Review of Resident R5's Elopement Evaluation Form dated 4/3/25, indicated Does the resident have a history of elopement or attempted leaving the facility without informing staff: Yes. Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: Yes. Does the resident wander: Yes. Does the resident wander aimlessly or non-goal-directed (i.e. confused, moves with purpose, may enter others' rooms and explore others' belongings): Yes. Elopement score of four. Review of the admission Record indicated Resident R6 was admitted to the facility on [DATE], with diagnoses of heart failure (heart doesn't pump blood as well as it should), insomnia, and hyperlipidemia. Review of Resident R6's Elopement Evaluation Form dated 5/12/25, indicated Does the resident wander: Yes. Elopement score of one. Review of the admission Record indicated Resident R7 was admitted to the facility on [DATE], with diagnoses of coronary artery disease (narrow arteries decreasing blood flow to heart), high blood pressure, and heart failure. Review of Resident R7's MDS dated [DATE], indicated the diagnoses remain current. Review of Resident R7's Elopement Evaluation Form dated 4/26/25, indicated Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: Yes. Does the resident wander: Yes. Is the wandering behavior a pattern, goal-directed (i.e. specific destination in mind, going home etc.): Yes. Elopement score of three. Review of the admission Record indicated Resident R8 was admitted to the facility on [DATE], with diagnoses of anemia, high blood pressure, and Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). Review of Resident R8's MDS dated [DATE], indicated the diagnoses remain current. Review of Resident R8's Elopement Evaluation Form dated 3/3/25, indicated Does the resident have a history of elopement or attempted leaving the facility without informing staff: Yes. Does the resident wander: Yes. Does the resident wander aimlessly or non-goal-directed (i.e. confused, moves with purpose, may enter others' rooms and explore others' belongings): Yes. Elopement score of three. Review of eight of eight exit seeking/wandering resident care plans mimicked each other and did not identify any resident person-centered interventions and/or goals specific to each resident. -Resident R1's care plan dated 5/13/25. -Resident R2's care plan dated 5/20/25. -Resident R3's care plan dated 5/21/25. -Resident R4's care plan dated 4/2/25. -Resident R5's care plan dated 4/3/25. -Resident R6's care plan dated 5/15/25. -Resident R7's care plan dated 5/21/25. -Resident R8's care plan dated 5/14/25. Eight of eight resident care plans had almost identical goals of the following: -The resident's safety will be maintained through the review date. -The resident will demonstrate happiness with daily routine through the review date. -The resident will not leave facility unattended through the review date. Eight of eight resident care plan interventions had almost identical interventions of the following: -Assess for fall risk -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book resident prefers: -Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. -Monitor for fatigue and weight loss. -Provide structured activities; toileting walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Interview on 5/23/25, at 11:30 a.m. the Director of Nursing confirmed the facility failed to make certain exit seeking/wandering residents had a person-centered care plan individualized to each specific resident's needs for eight of 35 residents identified as high risk for wandering/elopement (Residents R1, R2, R3, R4, R5, R6, R7, and R8). 28 Pa. Code 201.24(e)(1)-(5) Admissions Policy 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

May 2025 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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Based on review of facility policy and documents, clinical record, and staff interviews, it was determined the facility failed to ensure that residents received adequate supervision and assistance to prevent accidents, which resulted in actual harm, as evidenced by a patella (knee) fracture, for one of two residents reviewed (Resident R1). Findings include: Review of facility policy, Skilled Nursing - Investigation of incidents update August 2024, indicated the purpose is to establish guidelines for investigations of incidents and accidents to determine the root cause of the event and to identify systemic changes and measures needed to prevent future incidents. The facility will conduct a thorough and timely investigation of incidents and accidents. If the accident/incident is related to resident care, in order to decide whether or not to substantiate abuse/neglect, begin by establishing the facts of the situation. Review of the clinical record indicated Resident R1 was admitted to facility 4/7/2020. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 3/4/25, included diagnoses epilepsy (brain condition that causes reoccurring seizures), history of falls, and muscle weakness. Section C0500 the Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact. Resident 1's score of 15. Review of Resident R1's clinical record progress note date 4/7/25, at 1:55 p.m., indicated CNA (nurse aide) came to this nurse due to resident complaining of pain. Resident stated that the driver was transferring her off the van and her left leg fell off the footrest and her left leg dragged under the wheelchair, and she told him to stop, and he keep pushing her in the wheelchair and she then came back to the facility and keep feeling the pain in her left leg. This nurse contacted CRNP (certified registered nurse practitioner) to obtain x-ray on the left leg tib (tibia), fib (fibula), knee. Review of facility submitted information dated 4/8/25, indicated, Resident R1 was complaining of left leg pain. Resident R1 stated her leg fell off the leg rest and got caught under the wheelchair during transport from her audiology appointment earlier in the day. The driver accidentally dragged her foot under the wheelchair causing her to say, ouch, stop. The knee was painful to touch and slightly swollen. CRNP was notified and ordered imaging. Imaging showed a patella fracture to left leg. Order obtained to send Resident R1 to the hospital for evaluation. The driver stated, her leg fell off the footrest and he didn't notice. He also stated that he did not realize she was hurt so he did not notify anyone. Review of facility provided document dated 4/7/25, indicated that Van Driver (VD) Employee E1 was transporting Resident R1 back to the facility from an appointment. He (Employee E1) took her (Resident R1) down the lift with no issue. After getting into building, Resident R1 said Ouch, which alerted Employee E1 to stop and see what the issue was; he noticed that the footrest had fallen off and that her (Resident R1) left leg was caught under the wheelchair. He (Employee E1) pulled the wheelchair backwards to get her leg free. He picked up the footrest, placed it back on the wheelchair, and put her (Resident R1) foot back on the footrest. Review of an employee statement written by Receptionist Employee E2 dated 4/17/25, indicated that Resident R1 was coming from an appointment. As the driver was pushing her through the first set of sliding doors, a scream of pain was heard. The second set of doors opened, and a bystander stopped them and put her foot back on the footrest; it was bent under the footrest. Resident R1 told him (VD Employee E1) that she was okay, and they went to the elevator. Review of facility provided document dated 4/7/25, indicated a diagnostic X-ray (medical imaging used to capture pictures of the inside of the body, particularly the bones) was completed of the left knee revealing a mid-patella fracture. Review of emergency room documentation dated 4/8/25, indicated that Resident R1 was treated for acute nondisplaced transverse fracture inferior patella of the left leg. Review of Resident R1's clinical progress note dated 4/8/25, at 4:28 a.m., indicated resident returned from hospital. Left leg in locking brace. Discharge instructions reviewed and approved by physician services. During an interview on 5/8/25, at 2:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON) confirmed that the facility failed to ensure that residents received adequate supervision and assistance to prevent accidents, which resulted in actual harm, as evidenced by a patella fracture, for one of two residents reviewed (Resident R1). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies.

Nov 2024 15 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for one of nine residents (Resident R46). Findings include: Review of facility policy Nursing-Medication and treatment orders dated 8/24 indicated medications shall be administered only upon written order of duly Licenced and authorized to prescribe such medications in this state. Review of the admission record indicated Resident R46 was admitted to the facility on [DATE], with diagnosis that include morbid obesity, congestive heart failure (serious condition that occurs when the heart can't pump enough blood to meet the body's needs) and diabetes mellitus. Observation on 11/18/24, at 10:15 a.m. Resident R46 was laying in bed, on bed side table there was a cup with 4 pills. Resident R46 stated she had dropped a pill and didn't know where it was located. During and interview on 11/18/24, at 10:45 a.m. Registered Nurse (RN) Employee E4 confirmed Resident R46 did not have orders for mediation self-administration. 28. Pa. Code 211.12(d)(1)(2) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0638 (Tag F0638)

Could have caused harm · This affected 1 resident

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Based on review of the Resident Assessment Instrument (RAI) Users Manual, clinical record review, and staff interview, it was determined that the facility failed to timely complete a quarterly Minimum Data Set (MDS) assessment for one of nine residents. (Resident 144) Findings include: The Long-Term Care Facility RAI User's Manual, which provides instructions and guidelines for completing required MDS assessments (mandated assessments of a resident's abilities and care needs), revised October 2023, indicates that quarterly assessments must be no more than 92 days after the Assessment Reference Date (ARD) of the most recent assessment, and the assessment was to have a completion date that was no later than the ARD plus 14 calendar days. Clinical record review revealed that Resident 144 had an admission MDS assessment completed on 6/6/24. There was no evidence that any MDS assessment, including a quarterly assessment, had been completed after 6/6/24. Review of Resident R144's clinical record on 11/21/24, indicated a quarterly MDS assessment was to be completed by 9/20/24. It was 62 days overdue. During an interview on 11/21/24, at 9:53 a.m., Registered Nurse Assessment Coordinator, Employee E11 confirmed the facility failed to timely complete a quarterly MDS assessment for one of nine sampled residents. (Resident 144) 28 Pa. Code 211.5(f) Clinical Records.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for two of two residents (Resident R36 and R158). 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 2023, indicated the following instructions: -Observation (Look-Back, Assessment) Period is the time period over which the resident's condition or status is captured by the MDS assessment. Most MDS items themselves require an observation period, such as 7 or 14 days, depending on the item. Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the observation period must also cover this time period. A standard 7-day look-back period counts back from and includes the Assessment Reference Date (ARD+6 previous days). -Section C: Resident interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available. Review of Resident R36's admission record indicated she was admitted to the facility on [DATE], with diagnoses of aphasia (a disorder that results from damage to portions of the brain that are responsible for language) and dysphagia (difficulty swallowing). Review of Resident R36's MDS assessment dated [DATE], indicated the diagnoses were current. Section B: Hearing, Speech, and Vision, question B0700 measures the resident's ability to express ideas and wants indicated that Resident R36 is understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R36 is rarely/never understood, and the BIMS (brief interview for mental status) assessment was not completed. During an attempted interview conducted on 11/18/24, at 10:30 a.m. Resident R36 was unable to be understood. During an interview on 11/20/24, at 11:42 a.m. Licensed Practical Nurse, Employee E13 confirmed Resident R36 does not speak and cannot be understood. Review of Resident R158's admission record indicated he was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of Parkinson's Disease (a movement disorder of the nervous system that worsens over time), high blood pressure, and anxiety. Review of Resident R158's progress note dated 9/10/24, at 1:49 p.m. indicated the resident was transferred to the hospital due to altered mental status, hypoxia (low oxygen levels), respiratory failure, fever, and high blood pressure. Review of Resident R158's MDS dated [DATE], Section A2105. Discharge Status indicated the resident was discharged to home/community). During an interview on 11/21/24, at 2:56 p.m. the Nursing Home Administrator and DON confirmed the facility failed to ensure that MDS assessments accurately reflected the resident's status for two of two residents (Resident R36 and R158). 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing Services.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical records and staff interview, it was determined that the facility failed to update a care plan for one of two residents (Resident R316) to accurately reflect the current status of the resident. Findings include: Review of facility policy Comprehensive Care Plan dated 8/24 indicates a comprehensive person centered care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and physiological needs is developed for each resident. Review of clinical record indicated Resident R316 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (serious condition that occurs when the heart can't pump enough blood to meet the body's needs), asthma and atrial fibrillation a heart condition that causes an irregular and often rapid heartbeat in the upper chambers of the heart). Review of Resident R316's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated 11/9/24, indicated the diagnoses remain current. Review of Resident R316's physician orders dated 11/3/24 indicated 1800 fluid restriction. Review of Resident R316's Resident Care Plan Summary Report (report nurse aides used to know what kind of care to provide) dated 11/13/24, indicated to encourage fluids. During an interview on 11/20/24, at 2:00 p.m. Director of Nursing (DON) confirmed the facility failed to revise care plan for Resident R316. 28 Pa. Code: 211.11(d) Resident Care Plan

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a resident's interview, clinical record review and review of the facility policy, it was determined that the facility failed to provide the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including communication (Resident R36), and eating (Resident R60) for two of seven residents. Finding include: Review of the facility policy titled, Nutritional Assessment and Care Plan last reviewed 8/24, indicated the Dietician will complete a comprehensive nutritional assessment and nutritional care plan for each resident to be individualized to that resident's nutritional problems and/or needs. The information will be documented in the resident's clinical record. Review of Resident R36's admission record indicated she was admitted to the facility on [DATE], with diagnoses of aphasia (a disorder that results from damage to portions of the brain that are responsible for language) and dysphagia (difficulty swallowing). Review of Resident R36's MDS assessment dated [DATE], indicated the diagnoses were current. Review of Resident R36's progress note dated 3/15/24, indicated the resident has expressive aphasia. It was stated the resident's speech is unclear and she has a language barrier. It was indicated the resident is rarely/never makes self understood, however the resident usually understands others. Review of Resident R36's progress note dated 4/8/24, indicated it was difficult to obtain a full review of systems due to much of speech being repetitive and incomprehensible. However, she will answer yes and no to some very simple questions. During an attempted interview conducted on 11/18/24, at 10:30 a.m. Resident R36 was unable to be understood and was incomprehensible. Review of Resident R36's clinical record on 11/20/24, failed to include a care plan to address Resident R36's communication needs. During an interview on 11/20/24, at 11:42 a.m. Licensed Practical Nurse, Employee E13 confirmed Resident R36 does not speak and cannot be understood. It was indicated the resident puts blanket over her head and shakes her head. LPN, Employee E13 confirmed Resident R36 does not have a communication device. During an interview on 11/20/24, at 12:54 p.m. the Director of Nursing confirmed the facility failed to ensure the appropriate treatment and services to maintain or improve Resident R36's ability to carry out the activities of daily living, for communication was provided. Review of Resident R60's admission record indicated she was admitted to the facility on [DATE], readmitted [DATE], with diagnoses of dysphagia (difficulty swallowing), depression, and hemiplegia (paralysis affecting one side of the body). Review of Resident R60's MDS assessment dated [DATE], indicated the diagnoses were current. Review of Resident R60's active physician order dated 8/1/23, indicated the resident is to be out of bed in a chair every day prior to lunch to help open lung fields and to have her meal out of bed. Review of Resident R60's active physician order dated 8/1/23, indicated the resident is to be out of bed for all meals. Review of Resident R60's care plan dated 8/6/23, indicated the resident has a swallowing problem due to coughing or choking during meals. During an observation and interview on 11/20/24, Resident R60 was observed sitting in bed eating lunch. Resident R60 indicated no one has offered to get her out of bed. She indicated usually on her shower days, staff do not get her out of bed for meals. During an interview on 11/20/24, at 12:13 p.m. LPN, Employee E14 stated they don't take her out of bed on shower days when asked why Resident R60 was not out of bed as ordered for lunch. During an interview on 11/20/24, at 2:48 p.m. the Director of Nursing and Nursing Home Administrator confirmed the facility failed to is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including communication (Resident R36), dining and eating (Resident R60). 28 Pa. Code 211.109d) Resident care policies 28 Pa. Code 211.12(c)(d)(1) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure vital signs parameters (value ranges) were documented on the medication administration record per physician orders for two of six residents (Resident R24, and R70), and failed to discontinue incisional care once healed for one of six residents (Resident R151). Findings include: Review of facility policy Nursing Documentation of Medication Administration dated August 2024, indicated the facility shall maintain a medication administration record to document all medications administered. Review of the facility policy Nursing - Medication and Treatment Orders dated August 2024, indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. Review of the admission record indicated Resident R24 admitted to the facility on [DATE]. Review of Resident R24's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/30/24, indicated the diagnosis of high blood pressure, Non-Alzheimer's Dementia (dementia caused by other diseases with symptoms forgetfulness, limited social skills, and impaired thinking abilities that interfere with daily functioning), and depression. Review of Resident R24's physician order dated 11/4/24, indicated losartan (a medication to treat high blood pressure) 25 milligrams (mg) by mouth at bedtime for high blood pressure. Hold medication if blood pressure is less than 110. Review of Resident R24's current care plan indicated the resident will remain free of complications related to high blood pressure through review date. Blood Pressure log as ordered. Review of Resident R24's Medication Administration Record (MAR) dated November 2024, indicated from 11/5/24, through 11/19/24, that Resident R24 received the losartan 25mg at bedtime. The parameter blood pressure at bedtime was not documented on the MAR. Review of Resident R24's Blood Pressure Summary log indicated from 11/4/24, through 11/17/24, blood pressure being recorded on nine occurrences. None of the recorded blood pressures were completed at bedtime, the time of administration of the losartan. Interview on 11/20/24, at 10:10 a.m. Registered Nurse (RN) Employee E8 confirmed the facility did not document the parameter of blood pressure at bedtime as ordered for Resident R24's losartan administration. Review of the admission record indicated Resident R70 admitted to the facility on [DATE]. Review of Resident R70's MDS dated [DATE], indicated the diagnosis of high blood pressure, Non-Alzheimer's Dementia, and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of Resident R70's physician order dated 11/11/24, indicated amlodipine besylate (a medication to treat high blood pressure) 5mg daily. Hold if systolic blood pressure is less than 100. Review of Resident R70's current care plan failed to include high blood pressure. Review of Resident R70's Medication Administration Record (MAR) dated November 2024, indicated from 11/12/24, through 11/19/24, that Resident R70 received the amlodipine besylate on seven occasions. The parameter blood pressure was not documented on the MAR. Review of Resident R70's Blood Pressure Summary log indicated from 11/1/24, through 11/19/24, blood pressure was recorded only one time on 11/1/24, prior to the start of the medication on 11/12/24. Interview on 11/20/24, at 10:10 a.m. RN Employee E8 confirmed the facility did not document the parameter of blood pressure as ordered for Resident R70's amlodipine besylate administration. Review of the admission record indicated Resident R151 was admitted to the facility on [DATE]. Review of Resident R151's MDS dated [DATE], indicated the diagnosis of Non-Alzheimer's Dementia, thyroid disorder, and hip fracture. Review of Resident R151's physician order dated 10/2/24, indicated wound care: cleanse incision to upper back with alcohol and cover with a Primapore dressing (a soft, water resistance, non-adherent wound dressing) one time a day. Review of Resident R151's current care plan indicated skin integrity: spinal (back) incision. Keep skin clean and moisturized. Review of Resident R151's Treatment Administration Record (TAR) dated November 2024, indicated the treatment was administered in the evening from 11/1/24, through 11/17/24. Observation on 11/19/24, at 9:47 a.m. Unit Manager Employee E2 provided privacy to Resident R151 and pulled clothing back to assess spinal incision. There was a healed incision from the base of the neck to lower back. There was not a dressing in place as ordered. Interview on 11/19/24, at 9:48 a.m. Unit Manager Employee E2 indicated They must have forgotten to discontinue the order. The incision is healed. Interview on 11/20/24, at 12:00 p.m. the Director of Nursing confirmed the facility failed to ensure vital signs parameters were documented on the MAR per physician orders for two of six residents (Resident R24, and R70), and failed to discontinue incisional care and treatment once healed for one of six residents (Resident R151). 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on review of facility policies, clinical records, facility documents and staff interviews, it was determined that the facility failed to ensure residents were assessed, and provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of three residents (Resident R72). Findings include: Review of facility policy Stage and Treat Pressure Injury, updated in August 2024, indicated the following: 1. Cleanse wound with normal saline before identification and measurement, unless contraindicated. 2. Describe appearance (redness, rash, puffiness, observe edges of wound). 3. Measure length, width, and depth of wound with disposable tape measure. 4. Inspect for drainage and odor. 5. Inspect for presence of eschar in wound bed. 6. Inspect for tunneling. 7. Use Staging Document in Reference options, to identify stage of wound 8. Initiate treatment identified in the Staging Document for the identified stage. Review of facility policy Document Wound and Pressure Injury, updated August 2024, indicated the following: 1. Document size: Measure in centimeters - Length = head to toe direction - Width = hip to hip direction - Depth = Measure deepest part of visible wound bed 2. Document any undermining, tunneling, or sinus tracts, document using the 'clock system' with the head being 12:00 (example: 2cm undermining at 3 o'clock) 3. Describe any exudates (drainage) type, amount, odor 4. Odor: presence or absence of odor 5. Describe characteristics of tissue in wound bed 6. Describe wound edges 7. Describe surrounding tissue: color, edema, firmness, intact, induration, pallor, lesions, texture, scar, rash, moisture 8. Describe indicators of infection 9. Document any pain or indicators of pain associated with wound or treatment 10. Document intervention for healing 11. Document current topical treatment plan, response to treatment, modifications to plan and/or implementation of new orders, reasons for NOT changing plan and any referrals 12. Document Resident Education. Review of facility policy Skilled Nursing - Comprehensive Care Plans, updated 2/7/24, indicated a comprehensive person-centered care plan that includes measurable objectives and timetables to meet resident's medical, nursing, mental and psychological needs is developed for each resident. Review of clinical record indicated that Resident R72 was admitted to facility 10/10/24, with diagnoses of left leg fracture, protein-calorie malnutrition, and diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident R72's clinical record Clinical Admission assessment, dated 10/10/24, failed to indicate the resident had any pressure injuries. Review of Resident R72's clinical record Skin Check assessment, dated 10/11/24, indicated a 5 x 5 cm open area on coccyx. The assessment failed to identify type, staging, and description of the open area. Review of Resident R72's active physician order dated 10/11/24, through 10/15/24, indicated to apply a butterfly dressing to the coccyx area. The dressing was ordered to be changed daily and PRN (as needed) for soilage. The facility failed to enter an order to cleanse the resident's stage three pressure ulcer. Review of Resident R72's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/16/24, indicated diagnoses remain current upon review. Skin Condition - Section M0100 indicated that resident had a pressure ulcer/injury; Section M0210 indicated yes this resident has one or more unhealed pressure/ulcer injuries; Section M0300C. indicated a 1 for the number of Stage 3 (full-thickness skin loss with damage to subcutaneous tissue extending down to (but not including) the underlying fascia) pressure ulcers present on admission. Section V - Care Area Assessment (CAA) Summary, V200, A. CAA Results indicated an X that Pressure Ulcer Care Area triggered, and indicated an X that Care Planning Decision was made. Review of facility provided document Pressure Report, current on 11/18/24, indicated that Resident R72 was admitted to the facility with a stage 3 pressure ulcer. During an interview on 11/20/24, at 9:35 a.m., the Director of Nursing (DON) confirmed that the facility failed to have a physician order to cleanse the resident's coccyx pressure ulcer from 10/10/24, through 10/15/24. Review of Resident R72's current plan of care on 11/20/24, failed to include a pressure ulcer care plan. During an interview on 11/20/24, at 10:50 a.m., Resident Nurse Assessment Coordinator (RNAC) Employee E11 stated that he failed to care plan goals and interventions for Resident R72's stage 3 coccyx pressure injury. During an interview on 11/20/24, at 12:30 p.m., Wound Care Nurse (WCN) Employee E10 indicated that per her knowledge and best practice, physician orders for wound care should include cleansing, treatment, and dressing instructions. WCN Employee E10 stated that Resident R72 should have had physician orders to cleanse the resident's coccyx wound from 10/11/24, through 10/15/24. During an interview on 11/22/24, at 12:15 p.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to ensure residents were assessed, and provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer for one of three residents (Resident R72). 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 four residents reviewed (Resident R60). Findings include: Review of Resident R60's admission record indicated she was admitted to the facility on [DATE], readmitted [DATE], with diagnoses of dysphagia (difficulty swallowing), depression, and hemiplegia (paralysis affecting one side of the body). Review of Resident R60's MDS assessment dated [DATE], indicated the diagnoses were current. Review of Resident R60's [NAME] (care plan chart or template used by nurses to summarize important information about a patient's needs on 11/19/24, indicated the resident will wear palm guard daily on in the morning and off at dinner time. During an observation and interview on 11/20/24, Resident R60 was observed without a palm guard. Resident R60 indicated no one has offered to apply her palm guard. She indicated usually on her shower days, staff do not apply her palm guard. During an interview on 11/20/24, at 12:13 p.m. LPN, Employee E14 stated Resident R60 is not taken out of bed on her shower days, and that's probably why her palm guard was not put on. During an interview on 11/20/24, at 2:48 p.m. the Director of Nursing and Nursing Home Administrator confirmed the facility failed to ensure that physician-ordered contracture management interventions were provided as care planned for one of four residents reviewed (Resident R60). 28 Pa. Code 211.12(d)(5) Nursing Services.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0728 (Tag F0728)

Could have caused harm · This affected 1 resident

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Based on review of facility provided documents, personnel files, and staff interview, it was determined that the facility failed to ensure nurse aides who failed to become certified within four months were not working in the facility for one of five Employees (Nurse Aide Trainee Employee E12). Findings Include: Review of Title 42 Code of Federal Regulations §483.35(d) Requirement for facility hiring and use of nurse aides- §483.35(d)(1) General rule. A facility must not use any individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, unless- (i) That individual is competent to provide nursing and nursing related services; and (ii)(A) That individual has completed a training and competency evaluation program, or a competency evaluation program approved by the State as meeting the requirements of §483.151 through §483.154. Review of facility provided documentation dated 11/7/24, indicated it was reported to facility administration that Nurse Aide Trainee Employee E12 failed to obtain the certified nurse aide within 120 days of working in a nurse aide training and testing program as required. The Nurse Aide Trainee Employee E12 completed the training program, however, was not able to successfully pass the written exam as required resulting in the non-certified aide providing direct care to residents on 10/21/2024, 10/25/2024, 10/26/2024, 10/27/2024, 10/28/2024, 10/30/2024, 10/31/2024, 11/01/2024, 11/02/2024, 11/03/2024, 11/05/2024, and 11/06/2024. Interview on 11/22/24, at 1:00 p.m. the Nursing Home Administrator confirmed the facility failed to ensure nurse aides who failed to become certified within four months were not working in the facility for one of five Employees (Nurse Aide Trainee Employee E12). 28 Pa Code: 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0744 (Tag F0744)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of four residents reviewed (Resident 67). Findings include: Review of Resident R67's clinical record indicated she was admitted to the facility on [DATE], with a diagnosis of dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 67's Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated 4/4/24, indicated that the facility assessed Resident R67 as having a diagnosis of dementia and cognition was moderately impaired. A review of Resident R67's clinical record from 4/17/24, through 9/22/24, failed to indicate that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Interview on 11/20/24, at 1:56 p.m. with the Registered Nurse Assessment Coordinator, Employee E11 confirmed the facility had no further documentation that the facility developed and implemented individualized person-centered care plans to address Resident R67's dementia and cognitive loss prior to 9/23/24. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0808 (Tag F0808)

Could have caused harm · This affected 1 resident

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Based on review of facility policy, review of clinical record, observations and staff and resident interviews, it was determined that the facility failed provide food items consistent with the prescribed diet order for two of five residents observed during dining (Resident R60 and R74). Findings include: Review of facility policy Diet orders and notification of diet changes dated 8/24 indicates the first initial physician dietary order will be prescribed by the Attending physician. Review of physician orders for Resident R60 confirmed a diet order dated 8/1/23 for Regular diet, Pureed texture, Nectar/Mildly Thick consistency. During an observation on 11/19/24, at 10:02 a.m. Resident R60's was observed with a yellow, thin fluid in her cup. Interview with Licensed Practical Nurse (LPN) Employee E15 confirmed Resident R60 was not provided nectar/mildly thick consistency fluids. LPN, Employee E15 stated last week Resident R60 received regular apple juice instead of nectar/mildly thick apple juice. Interview with Director of Nursing (DON) on 11/19/24, at 10:14 a.m. confirmed Resident R60 should have had nectar thick liquids as ordered. Review of physician orders for Resident R74 confirmed a diet order dated 10/15/24 for Regular diet, Mechanical Soft Ground Meat texture, Nectar/Mildly Thick consistency. During observations during dining, on 11/18/24, at 12:15 p.m. revealed Resident R74's meal ticket indicated Nectar Thick Liquids. Observations revealed Resident R74 was served thin iced tea. Interview with Registered Nurse (RN) employee E4 confirmed the above-mentioned findings. Interview with Director of Nursing (DON) on 11/18/24, at 2:00 p.m. confirmed Resident R74 should have had nectar thick liquids as ordered. 28 Pa. Code 211.6(a) Dietary Services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0810 (Tag F0810)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, observations, and staff interview, it was determined that the facility failed to provide adaptive feeding devices for two of five residents (Resident R74). Findings include: Review of facility policy Diet orders and notification of diet changes dated 8/24 indicates the first initial physician dietary order will be prescribed by the Attending physician. Review of clinical record indicated Resident R74 was admitted to the facility on [DATE], with diagnoses of dementia, orthostatic hypotension and acute kidney failure. Review of Resident R74's care plan dated 8/19/24, indicated provide adaptive equipment for feeding as needed: Kennedy cup with meals. During an observation on 11/18/24, at 12:15 p.m. Resident R74 did not have Kennedy cup as care planned with lunch. Interview with Registered Nurse (RN) Employee E4 confirmed the above-mentioned findings. Interview with Director of Nursing (DON) on 11/18/24, ay 2:00 p.m. confirmed Resident R74 should have had a [NAME] cup as care planned. 28 Pa. Code 211.6(a) Dietary Service

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment for eight of 12 residents (Resident R3, R5, R70, R73, R76, R93, R113, and R361). Findings include: Review of the facility policy Resident Rights - Quality of Life - Homelike Environment dated August 2024, indicated the facility will provide residents with a safe, clean, comfortable, and homelike environment. Review of Title 42 Code of Federal Regulations §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Review of the admission record indicated Resident R3 was admitted to the facility on [DATE]. Observation on 11/18/24, at 10:30 a.m. of Resident R3's room indicated gouges in the wall behind the head of the bed. Tour and interview with Unit Manager Employee E2 on 11/19/24, at 9:47 a.m. confirmed Resident R3 had gouges in the wall behind the head of the bed. Review of the admission record indicated Resident R5 was admitted to the facility on [DATE]. Observation on 11/18/24, at 11:33 a.m. Resident R5 was seated in a wheelchair at the dining table. The frame and undercarriage of the wheelchair was covered with dust and dried debris. Interview on 11/18/24, at 11:34 a.m. Nurse Aide (NA) Employee E1 confirmed the wheelchair was covered with dust and dried debris. Review of the admission record indicated Resident R70 was admitted to the facility on [DATE]. Observation on 11/18/24, at 11:40 a.m. of Resident R70's room indicated gouges in the wall behind the head of the bed. Tour and interview with Unit Manager Employee E2 on 11/19/24, at 9:47 a.m. confirmed Resident R70 had gouges in the wall behind the head of the bed. Review of the admission record indicated Resident R73 was admitted to the facility on [DATE]. Observation on 11/18/24, at 11:43 a.m. Resident R73 was seated in a wheelchair visiting with family. The frame and undercarriage of the wheelchair was covered with dust and dried debris. Interview on 11/18/24, at 11:44 a.m. Environmental Aide Employee E3 confirmed R73's wheelchair was covered with dust and dried debris. Review of the admission record indicated Resident R76 was admitted to the facility on [DATE]. Observation on 11/18/24, at 11:44 a.m. of Resident R76's room indicated an uneven surface into the entrance of the bathroom that posed a safety hazard. The transition strip from bedroom to bathroom was missing. Tour and interview with Unit Manager Employee E2 on 11/19/24, at 9:47 a.m. confirmed Resident R76's transition strip from bedroom to bathroom was missing. Review of the admission record indicated Resident R93 was admitted to the facility on [DATE]. Observation on 11/18/24, at 10:39 a.m. Resident R93 was seated in a wheelchair. The frame, wheels, and undercarriage of the wheelchair was covered with dust and dried debris. Interview on 11/18/24, at 10:39 a.m. NA Employee E6 confirmed R93's frame, wheels, and undercarriage of the wheelchair was covered with dust and dried debris. Review of the admission record indicated Resident R113 was admitted to the facility on [DATE]. Observation on 11/18/24, at 10:16 a.m. Resident R113 was seated in a wheelchair with a right lateral support (positioning device) corroded in dried grime and debris. The wheelchair brakes, frame, and undercarriage were grossly corroded in dried grime and debris. Interview on 11/18/24, at 10:16 a.m. NA Employee E6 confirmed R113's right lateral support, wheelchair brakes, frame, and undercarriage were grossly corroded in dried grime and debris. Review of the admission record indicated Resident R361 was admitted to the facility on [DATE]. Observation on 11/18/24, at 9:54 a.m. of Resident R361's room indicated an uneven surface into the entrance of the bathroom that posed a safety hazard. The transition strip from bedroom to bathroom was missing. Tour and interview with Unit Manager Employee E2 on 11/19/24, at 9:47 a.m. confirmed Resident R361's transition strip from bedroom to bathroom was missing. Interview on 11/19/24, at 9:50 a.m. the Unit Manager Employee E2 confirmed that the facility failed to provide a safe, clean, comfortable, and homelike environment for eight of 12 residents (Resident R3, R5, R70, R73, R76, R93, R113, and R361). 28 Pa. Code 201.1(i)Resident rights. 28 Pa Code: 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and interview, the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice for four of four residents (Residents R12, R24, R44, and R60). Findings include: Review of facility policy Skilled Nursing-Oxygen Administration dated August 2024, indicated oxygen is administered residents who need it, consistent with professional standards of practice and the care plan. Oxygen is administered under orders of a physician unless in emergency an order can be obtained as soon as the situation is under control. Review of facility policy Skilled Nursing--Cleaning Changing Nasal Cannulas and Masks dated August 2024, indicated all residents who are receiving oxygen therapy shall have masks and nasal cannula tubing changed weekly and/or as needed. Review of admission record indicated Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/14/24, indicated the diagnoses of Non-Alzheimer's Dementia (dementia caused by other diseases with symptoms forgetfulness, limited social skills, and impaired thinking abilities that interfere with daily functioning), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and depression. Review of Resident R12's current physician orders indicated Ipratropium-Albuterol Inhalation Solution (medication to enhance breathing) give by nebulizer (machine turns medication into a mist to breath in) two times a day as needed for wheezing and coughing. Review of Resident R12's current care plan failed to indicate use of or management of Ipratropium-Albuterol Inhalation Solution or use of a nebulizer. Observation on 11/19/24, at 11:43 a.m., Resident R12's dresser had nebulizer tubing and equipment on the dresser. The equipment was not dated and not in a bag. Tour and interview with Unit Manager Employee E2 on 11/19/24, at 11:45 a.m. confirmed Resident R12's nebulizer tubing and equipment on the dresser, and the equipment was not dated and not in a bag as required. Review of the admission record indicated Resident R24 admitted to the facility on [DATE]. Review of Resident R24's MDS dated [DATE], indicated the diagnosis of high blood pressure, Non-Alzheimer's Dementia, and depression. Review of Resident R24's current physician orders failed to include orders for oxygen administration. Review of Resident R24's current care plan failed to indicate oxygen administration or management of it. Observation on 11/19/24, at 11:43 a.m. Resident R24's room had an oxygen concentrator (machine that provides oxygen) with humidification and nasal cannula. The humidification did not have a date, and the nasal cannula did not have a date, was on the floor, and not inside a bag. Interview on 11/19/24, at 11:43 a.m. Licensed Practical Nurse (LPN) Employee E9 confirmed the oxygen equipment was on the floor and did not have a date as required. Review of the admission record indicated Resident R44 admitted to the facility on [DATE]. Review of Resident R44's MDS dated [DATE], indicated the diagnosis of asthma, anxiety, and depression. Review of Resident R44's current physician order dated 8/1/23, indicated to administer 1 liter of oxygen via nasal canula every shift, wean as tolerated. Review of Resident R44's current physician order dated 8/4/23, indicated to change humidifier bottle, nasal canula and clean oxygen filter once a week when in use. Review of Resident R44's current physician orders dated 7/26/24, indicated to change oxygen tubing and humidifier every week. Review of Resident R44's current care plan failed to indicate oxygen administration or management of it. Observation on 11/18/24, at 11:18 a.m. Resident R44's room had an oxygen concentrator with humidification and nasal cannula. The humidification did not have a date, and the nasal cannula did not have a date. Observation and interview on 11/19/24, at 11:49 a.m. Resident R44's room had an oxygen concentrator with humidification and nasal cannula. The humidification did not have a date, and the nasal cannula did not have a date. Registered Nurse, Employee E19 confirmed Resident R44's humidification or oxygen was not dated. Interview on 11/20/24, at 10:29 a.m. the Director of Nursing confirmed Resident R44 did not have a care plan for her oxygen use. Review of the admission record indicated Resident R60 admitted to the facility on [DATE], and readmitted [DATE]. Review of Resident R60's MDS dated [DATE], indicated diagnoses of dysphagia (difficulty swallowing), Chronic Obstructive Pulmonary Disease (an ongoing lung condition caused by damage to the lungs), and hemiplegia (paralysis affecting one side of the body). Review of Resident R60's current physician order dated 6/13/24, indicated to administer 1 vial of Ipratropium-Albuterol Solution two times a day. Observation on 11/19/24, at 10:04 a.m. Resident R60's nebulizer tubing was observed hanging off the resident's counter not inside a bag. LPN, Employee E15 confirmed the facility failed to properly store nebulizer tubing properly when not in use. Interview on 11/22/24, at 1:00 p.m. the Director of Nursing confirmed the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice for four of four residents (Residents R12, R24, R44, and R60). 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0625 (Tag F0625)

Minor procedural issue · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record review and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of five residents hospital transfers (Resident R77, R96, R131). Findings include: Review of Resident R131's admission record indicated she was originally admitted on [DATE], with diagnoses that included anxiety disorder, depression and diabetes mellitus. Review of the clinical record indicated Resident R131 was transferred to hospital on 3/23/24 and returned to the facility on 3/28/24. Review of Resident R131's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 3/23/24. Review of Resident R77's admission record indicated she was originally admitted on [DATE], with diagnoses that included heart failure, hyperlipidemia and dysphagia. Review of Resident R77's clinical record revealed that the resident was transferred to the hospital on 7/26/24, and returned to the facility on 7/31/24, also 10/23/24 and returned to the facility 10/28/24. Review of Resident R77's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 7/26/24 and 10/23/24. Review of Resident R96's admission record indicated she was originally admitted on [DATE], with diagnoses that included fracture of right humerus, repeated falls and hyperlipidemia. Review of the clinical record indicated Resident R96 was transferred to hospital on [DATE] and returned to the facility on [DATE]. Review of Resident R96's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on [DATE]. During an interview on 11/21/24, at 11:15 a.m. Medical Records Employee E7 confirmed that the facility failed to notify the resident or resident's representative of the facility bed-hold policy for three of five residents hospital transfers as required (Resident R77, R96, R131). 28 Pa. Code 201.29 (a)(c.3)(2) Resident rights

Mar 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0800 (Tag F0800)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, observations, and staff interviews it was determined the facility failed to meet the daily nutritional and special dietary needs for one of six residents (Resident R1), and failed to have a structured meal delivery system to ensure residents received their meals accurately, and timely. Findings include: Review of the facility policy Dietary-Frequency of Meals and Snacks dated 12/6/23, indicated it is the responsibility of the Dining Services Department to see that each meal is served at the designated time unless there is an emergency. Review of the facility policy Skilled Nursing-Dietary Supplements dated 4/12/23, indicated it is the policy of this community that nutritional and dietary supplements will be used to complement a resident's dietary needs in order to maintain adequate nutritional status and resident's highest practicable level of well-being. Review of Resident R1's record indicated the resident was admitted to the facility on [DATE]. Review of the admission record indicated the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), chronic obstructive pulmonary disease (constricted airways cause difficulty or discomfort in breathing), and congestive heart failure (the heart doesn't pump blood effectively). Review of Resident R1's current physician orders dated 3/20/24, indicated a regular diet, with mechanical soft, ground meat texture, and Boost Plus two times a day. Review of Resident R1's care plan initiated 2/14/24, indicated the resident will maintain an adequate nutritional status as evidenced by maintaining weight. Interventions included provide and serve supplements as ordered Med Pass and Boost Plus two times a day (liquid supplements) at lunch and dinner. Report refusals to dietitian. Provide, serve diet as ordered and record every meal. Review of facility grievance log dated 3/19/24, indicated Resident R1 did not receive a lunch tray on 3/18/24. Interview on 3/20/24, at 11:30 a.m. Nurse Aide (NA) Employee E1 indicated staff take the meal tickets around in the morning and ask the residents who can answer what they'd like to eat in the morning. Observation of meal service in the Dining Room on 3/20/24, at 11:30 a.m. revealed several staff serving meals. An unidentified female resident was seated in the dining room, and NA Employee E1 indicated she's from the other side but she usually eats over here with us. When Survey Agency (SA) asked NA Employee E1 if the female resident's meal ticket was in the stack she was serving from, she stated I'm not sure, I think it's on the other side (middle dining area). Interview on 3/20/24, at 11:31 a.m. NA Employee E2 at the middle dining area indicated the female resident's tray ticket was on the first side. Interview on 3/20/24, at 11:32 a.m. NA Employee E1 at the first dining area indicated she had located the female resident's tray ticket. Observation on 3/20/24, at 11:35 a.m. Resident R1 was observed lying in bed, visiting with family who brought lunch from home for resident. Interview with Resident R1's family on 3/20/24, at 11:35 a.m. indicated the other day, Resident R1 didn't receive a lunch tray and it's happened a few times before. Family also indicated he's supposed to be getting Boost Plus twice a day and he hasn't had it in a while. Observation of lunch tray in room on 3/20/24, at 11:35 a.m. revealed ground Caribbean shrimp, liquefied cauliflower/cheddar soup, potato wedges, ground Italian vegetable blend, Boston crème pie. Two iced teas. The tray ticket also indicated Extra Items of Boost Chocolate and strawberry ice cream. The tray had no Boost Chocolate and the strawberry ice cream was fat free. During the observation in Resident R1's room on 3/20/24, at 11:37 a.m. NA Employee E3 brought another lunch tray in that had a chicken pot pie, mashed potatoes, gravy, two iced teas, and regular strawberry ice cream. There was not a Boost Plus on the tray. When questioned, on 3/20/24, at 11:38 a.m. NA Employee E3 indicated she didn't realize someone had already brought him a tray. They must have brought it from the other side. She confirmed the first tray had fat free strawberry ice cream and that neither tray had Boost Plus on it. Interview on 3/20/24, at 11:42 a.m. NA Employee E4 indicated the other side must have given Resident R1 a tray too and they did not realize there was not a Boost Plus on the tray. Interview on 3/20/24, at 11:43 a.m. NA Employee E2 indicated We haven't had Chocolate Boost Plus in a long time. I just give Resident R1 chocolate milk because he doesn't like vanilla and that's all they can get. Interview on 3/20/24, at 1:01 p.m. Registered Dietitian (RD) Employee E5 indicated We've had supply issues with the Chocolate Boost Plus on and off since the pandemic. Currently we can get Ensure but only in vanilla. RD Employee E5 confirmed the Boost Plus had 360 calories and 14 grams of protein, while the facility's chocolate milk provided only 211 calories and only eight grams of protein per serving, and that it was not an equivalent substitution. Interview on 3/20/24, at 2:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to meet the daily nutritional and special dietary needs for one of six residents (Resident R1), and failed to have a structured meal delivery system to ensure residents received their meals accurately, and timely on a consistent basis. 28 Pa. Code: 201.18(b)(1)(e)(1) Management 28 Pa. Code: 201.12(d)(1)(3)(5) Nursing services 28 Pa. Code: 201.1(i)Resident rights. 28 Pa Code: 211.6(c)(d) Dietary Services

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that clinical records were complete and accurate for one of six residents reviewed (Resident R1). Findings include: Review of the facility policy Medical Records-The Medical Record date 12/12/23, indicated that the medical record will contain complete and accurate documentation, which clearly identifies the resident, justifies the diagnoses, condition, treatment, care approaches, and responses to the care provided. Review of Resident R1's admission record indicated the resident was admitted to the facility on [DATE], with the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), chronic obstructive pulmonary disease (constricted airways cause difficulty or discomfort in breathing), and congestive heart failure (the heart doesn't pump blood effectively). Review of Resident R1's current physician orders dated 3/20/24, indicated Boost Plus (liquid supplement) two times a day. Review of Resident R1's Medication Administration Record dated March 2024, indicated Boost Plus was administered two times a day from 3/1/24, through 3/19/24. Interview on 3/20/24, at 1:01 p.m. Registered Dietitian (RD) Employee E5 indicated We've had supply issues with the Chocolate Boost Plus on and off since the pandemic. They are supposed to be giving Ensure in place of it. Interview on 3/20/24, at 1:03 p.m. the Director of Nursing confirmed the nurses were documenting twice daily that Boost Plus was being administered, although they did not have Boost Plus in stock, and that the physician's orders should have been updated. Review of Resident R1's current physician orders dated 3/20/24, indicated an order from 2/13/24, for a low air loss mattress (prevents pressure), to be checked by nurse for function every shift. Observation 3/20/24, at 11:35 a.m. Resident R1 had a perimeter mattress on bed. Interview on 3/20/24, at 1:30 p.m. the Director of Nursing confirmed the low air loss mattress was not in place and that the physician order needed updated. Interview on 3/20/24, at 2:00 p.m. the Director of Nursing confirmed the facility failed to ensure that clinical records were complete and accurate for one of six residents reviewed (Resident R1). 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Nov 2023 17 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on review of facility policy, resident council group interview, resident and staff interview it was determined that the facility failed to offer residents the opportunity to vote for the November 2023 election (Second and Third floors). Findings include: The facility Resident rights-overview policy reviewed dated 6/23/23, and last reviewed 8/2023, indicated that residents have the right to exercise their rights as residents of the community and as citizens of the United States of America. During a resident council group interview on 11/14/23, at 1:00 p.m. seven out of seven residents indicated that they did not recieve assistance with voting registration for the election on November 2023. During an interview on 11/14/23, at 2:01 p.m. the Activities director Employee E3 stated that she has not been a part of voting registration process since she started her position. During an interview on 11/15/23, at 11:27 a.m. Resident R78 stated: I've been here 3-4 years. The social worker did her part to help me register. But i never received a ballot. I can't recall when that happened. During an interview on 11/15/23, at 11:32 a.m. Resident R112 stated: been here over one year. They did not ask me if I wanted to vote this year. During an interview on 11/15/23 11:43 a.m. the Social Worker Employee E4 stated that social services goes around and asks residents to vote. I have signed them up for reoccurring ballots. Typically, we do this. But, this past election we did not. During an interview on 11/15/23 02:35 p.m. Agency nurse aide (NA) Employee E5 stated that: activities goes around and asks residents about voting. i did not see that this year. During an interview on 11/15/23, at 3:07 p.m. the Director of Nursing (DON) confirmed that the facility failed to offer residents the opportunity to vote for the November 2023 elections. 28 Pa. Code 201.1(i)Resident rights.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and records, and a staff interview, it was determined that the facility failed to notify a physician for a change in condition for one of four residents reviewed (Resident R5). Findings: A review of the Change in a Resident's Condition or Status policy dated 4/10/23, last reviewed 8/23, indicated the facility shall promptly notify the reisdent's attending physician of changes in the resident's status. It was indicated the nutse supervisor or charge nurse must notify the resident's attending physician or on-call physician when there has been a significant change in resident's physical condition. It was indicated a significant change of condition is a decline in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions or impacts more than one area of the resident's health status. A review of the clinical record indicated that Resident R5 was admitted to the facility on [DATE], with diagnoses that included muscle weakness, cerebral palsy (group of disorders that affect movement, muscle tone, balance, and posture), and anemia (deficiency of healthy red blood cells in blood). A review of Resident R5's MDS dated [DATE], indicated the diagnosis were current. A review of Resident R5's Skin Evaluation Form dated 4/8/23, indicated the resident developed a 6 cm x 1.5 cm Right Buttock Partial Thickness Moisture Associated Skin Damage. It was documented there was undermining on the wound edge. The facility failed to correctly identify Resident R5's pressure ulcer. There was no evidence the physician was notified. A review of Resident R5's physician order dated 6/7/23, indicated to complete a sacral x-ray to rule our osteomyelitis due to pain for wound care. A review of Resident R5's Diagnostic X-Ray Service report dated 6/7/23, indicated the resident received a sacrum and coccyx x-ray that was negative for fracture or dislocation. It was indicated a three-phase bone scan or MRI examination with contrast are preferred modalities for the detection of osteomyelitis (infection of the bone). It stated, conventional radiographs may be relatively insensitive in the detection of early osteomyelitis changes. A review of Resident R5's progress note dated 6/17/23, indicated the resident's wound was odorous with slough (yellow/white layer of dead skin) noted at wound edges. There was no documentation that a physician was notified of the resident's newly developed wound odor. A review of Resident R5's clinical record from 6/17/23, through 11/16/23, failed to include evidence that a wound culture, bone scan, or MRI was completed to rule out an infection. A review of Resident R5's progress note dated 6/20/23, entered by Physician Assistant, Employee E15 indicated the resident had a right buttock 'Stage 4 Pressure Injury that measured 6.9 cm x 6.5 cm x 3cm. It was indicated there was a moderate amount of sero-sanguineous drainage was noted. There was a mild odor and eschar (dead tissue) was observed in wound bed. The peri wound skin exhibited scarring. The wound was debrided (a procedure to remove debris or infected/dead tissue from a wound) and post debridement measurements were 7 cm x 6.6 cm x 3.1 cm. The wound deteriorated. There was no documentation that the resident's physician was notified of the wound odor. A review of Resident R5's progress note dated 6/23/23, entered by Physician Assistant, Employee E15 indicated the resident had a right buttock 'Stage 4 Pressure Injury that measured 4 cm x 5.4 cm x 4 cm. The wound had undermining (caused by erosion under the wound edges, resulting in a large wound with a small opening) noted at 6:00 and ends at 2:00 with a maximum distance of 3.5 cm. It was indicated there was a moderate amount of sero-sanguineous drainage noted. There was a mild odor and eschar was observed in wound bed. The peri wound skin exhibited scarring. The wound was debrided, and post debridement measurements were 4.1 cm x 5.5 cm x 4.1 cm. There was no documentation that the resident's physician was notified of the wound odor. A review of Resident R5's progress note dated 6/28/23, entered by Physician Assistant, Employee E15 indicated the resident had a right buttock 'Stage 4 Pressure Injury that measured 4.2 cm x 3.8 cm x 3.3 cm. The wound had undermining noted at 8:00 and ends at 2:00 with a maximum distance of 4.3 cm. It was indicated there was a moderate amount of sero-sanguineous drainage noted. There was a mild odor. Slough and eschar were observed in wound bed. The peri wound skin exhibited scarring. The wound was debrided, and post debridement measurements were 4.3 cm x 3.9 cm x 3.4 cm. The wound care orders were updated to cleanse wound with 0.125% Dakin's solution and apply negative pressure wound therapy (NPWT) with a black sponge set at a continuous suction of 125mmhg. It was indicated the wound dressing must be changed three time per week. There was no documentation that the resident's physician was notified of the wound odor. A review of Resident R5's progress note dated 7/9/23, entered by Physician Assistant, Employee E15 indicated the resident had a right buttock 'Stage 4 Pressure Injury that measured 3.6 cm x 3.8 cm x 3 cm. The wound had undermining noted at 8:00 and ends at 2:00 with a maximum distance of 4 cm. It was indicated there was a moderate amount of sero-sanguineous drainage with a mild odor. Slough was observed in wound bed. The peri wound skin exhibited scarring. The wound was debrided, and post debridement measurements were 3.7 cm x 3.9 cm x 3.1 cm. There was no documentation that the resident's physician was notified of the wound odor. A review of Resident R5's progress note dated 7/12/23, entered by Physician Assistant, Employee E15 indicated the resident had a right buttock 'Stage 4 Pressure Injury that measured 3.1 cm x 3.3 cm x 1.5 cm. The wound had undermining noted at 8:00 and ends at 2:00 with a maximum distance of 3.5 cm. It was indicated there was a moderate amount of sero-sanguineous drainage with a mild odor. Slough was observed in wound bed. The peri wound skin exhibited scarring. The wound was debrided, and post debridement measurements were 3.2 cm x 3.4 cm x 1.6 cm. There was no documentation that the resident's physician was notified of the wound odor. A review of Resident R5's Skin Only Evaluation form dated 8/11/23, indicated the resident had a Stage 4 coccyx pressure injury. No measurements were documented. It was indicated the wound had an odor and undermining. The wound bed had slough. There was no documentation that the resident's physician was notified of the wound odor. A review of Resident R5's Nursing Advanced Skilled Evaluation form dated 8/18/23, indicated the resident had a Stage 4 coccyx pressure ulcer that measured 4.3 cm x 7 cm. Depth was not documented. It was indicated the wound bed had slough, and an odor and undermining were observed. There was no documentation that the resident's physician was notified of the wound odor. A review of Resident R5's Nursing Advanced Skilled Evaluation form dated 8/21/23, indicated the resident had a Stage 4 coccyx pressure ulcer that measured 4.3 cm x 7 cm. Depth was not documented. It was indicated the wound bed had slough, and an odor and undermining were observed. There was no documentation that the resident's physician was notified of the wound odor. During an interview on 11/16/23, at 1:43 p.m. the Director of Nursing (DON) confirmed the facility failed to notify a physician for a change in condition for one of seven residents reviewed (Resident R5.) 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, documents and clinical records and staff interviews, it was determined that the facility failed to protect residents from physical abuse for one of two residents reviewed (Resident R12). Findings include: Review of facility policy, titled Skilled Nursing-Abuse revised August 2023, revealed, that it is the policy of the community that each resident will be free from abuse. Abuse will mean all forms of abuse, neglect, exploitation and misappropriation. None of this will be tolerated. The community will educate staff and other applicable individuals in techniques to protect all parties. Abuse allegations are reported per Federal and State law. Employees must always report any abuse or suspicions of abuse immediately to the Administrator. Review of admission record indicated that Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/3/23, indicated diagnoses unspecified dementia with behavior disturbances (a diagnosis of dementia that does not specify the cause or type of dementia which may experience changes in mood and behavior, such as impaired concentration, apathy, anxiety, and agitation), generalized anxiety disorder (a condition with exaggerated tension, worrying, and nervousness about daily life events), and cognitive communication deficit (difficulties with thinking and how someone uses language). Section B indicted that resident sometimes is understood, and sometimes understands. Section C indicated that resident was unable to complete Brief Interview for Mental Status, and cognitive skills for daily decision making is severely impaired. Review of facility submitted documentation dated 10/13/23, revealed that an incident had occurred on 10/4/23, at approximately 10:30 p.m. It was reported that Nurse Aide (NA) Employee E7 told a resident (Resident R12) to shut up and applied scotch tape over resident's mouth for a few seconds and then removed it telling her Now be quiet. Further review of facility submitted report revealed that several staff members were at the nurses' station waiting on the next shift to give report. Resident R12 was exhibiting distress reactions and yelling out for help and praying loudly. Staff observed NA Employee E7 tell Resident R12 to shut up or she was going to tape her mouth shut. Resident R12 continued to yell and NA Employee E7 reached for the tape dispenser and put a piece of tape over Resident R12's mouth for a few seconds. NA Employee E7 then removed the tape and said now be quiet. Further review of the facility submitted documentation revealed that Nurse Aide (NA) Employee E8 reported the incident 10/13/23, to Registered Nurse (RN) Employee E9, at 10:30 a.m., at which time the investigation was initiated by management. Review of Nurse Aide (NA) Employee E8 witness statement dated 10/13/23, indicated that on a 3-11 shift, staff were sitting at the nurses station waiting for relief, when Resident R12 was doing her normal behaviors of help me, yelling, all of the normal we are used to. Witness statement further indicted that Employee E7 told Resident R12 to shut up or she was going to tape her mouth shut. Statement further indicated that Resident R12 continued her behaviors and Employee E7 reached for the tape dispenser and put a piece of tape over her (R12's) mouth for a few seconds. Employee E7 then removed the tape and told the resident to be quiet. Review of Nurse Aide (NA) Employee E22 witness statement dated 10/14/23, indicated that it was the end of shift we were all at the desk waiting for relief. I heard her (Employee E7) say that she should put a piece of tape on her (Resident R12) mouth, but I never saw her do it. Review of Nurse Aide (NA) Employee E7 witness statement dated 10/13/23, indicated that I jokingly put a piece of tape on (Resident R12)'s mouth and took it back of didn't do it to be cruel! Sorry, I am not a bad person. Further review of facility submitted documentation revealed that Resident R12 was unable to be interviewed due to resident is cognitively impaired with diagnosis of dementia, and was unable to recall incident. Further review of facility submitted documentation revealed a clinical progress note Late Entry dated 10/13/23, by RN Employee E9, assessed resident for injury and distress and neither was noted. Further review of facility submitted documentation revealed that on 10/13/23, NA Employee E7 was terminated due to resident abuse. Further review of facility submitted documentation revealed that between 10/13/23 and 10/16/23, facility staff were reeducated on abuse and neglect, reporting and identifying by Nursing Administration. Further review of facility submitted documentation dated 10/13/23, revealed that Employee E22 and E23 received verbal counseling for failure to report witnessed abuse timely. On 11/3/23, Employee E8 received Corrective Action Written Warning for failure to report abuse incident to supervisor immediately. Interviews conducted on 11/17/23, at 9:20 a.m., with 3 unit staff member (Unit Clerk (UC) Employee E24 , NA Employee E25, and NA Employee E26) on the [NAME] unit, revealed knowledge on facilities abuse policy and the proper process for identifying and reporting abuse timely. During an interview on 11/15/23, at 3:20 p.m., the Director of Nursing and the Nursing Home Administrator confirmed that the facility failed to protect residents from physical abuse for one of two resident reviewed (Resident R12). 28 Pa Code: 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on facility policy, review of facility submitted documentation, and staff interview, it was determined that the facility failed to ensure all alleged violations involving abuse were reported immediately for one of two residents reviewed for abuse (Resident 12). Findings include: Review of facility policy, titled Skilled Nursing-Abuse revised August 2023, revealed, that abuse allegations are reported per Federal and State law. Employees must always report any abuse or suspicions of abuse immediately to the Administrator. Review of facility submitted documentation dated 10/13/23, revealed that an incident had occurred on 10/4/23, at approximately 10:30 p.m. It was reported that Nurse Aide (NA) Employee E7 told a resident (Resident R12) to shut up and applied scotch tape over resident's mouth for a few seconds and then removed it telling her Now be quiet. Further review of facility submitted report revealed that several staff members were at the nurses' station waiting on the next shift to give report. Resident R12 was exhibiting distress reactions and yelling out for help and praying loudly. Staff observed NA Employee E7 tell Resident R12 to shut up or she was going to tape her mouth shut. Resident R12 continued to yell and NA Employee E7 reached for the tape dispenser and put a piece of tape over Resident R12's mouth for a few seconds. NA Employee E7 then removed the tape and said now be quiet. Further review of the facility submitted documentation revealed that Nurse Aide (NA) Employee E8 reported the incident 10/13/23, to Registered Nurse Employee E9, at 10:30 a.m., at which time the investigation was initiated by management. During an interview on 11/15/23, at 3:20 p.m., the Director of Nursing and the Nursing Home Administrator acknowledged that an incident of alleged abuse was not reported timely by staff who witnessed and that individual and staff-wide training was completed as a result. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record, and staff interview, it was determined that the facility failed to complete a comprehensive assessment after a significant change in condition for one of five residents receiving hospice services (Resident R5). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a significant change in status assessment is required to be performed when a terminally ill resident enrolls in a hospice program and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14-days from effective date of the hospice election. A review of the clinical record indicated that Resident R5 was admitted to the facility on [DATE], with diagnoses that included muscle weakness, cerebral palsy (a group of disorders that affect movement, muscle tone, balance, and posture), and anemia (deficiency of healthy red blood cells in blood.) A review of Resident R5's MDS dated [DATE], indicated the diagnosis were current. A review of Resident R5's physician order dated 8/29/23, indicated the resident was admitted to hospice. A review of Resident R5's clinical record from 8/29/23, through 9/12/23, failed to include a significant change MDS assessment was completed. During an interview on 11/15/23, at 1:18 p.m. Registered Nurse Assessment Coordinator (RNAC), Employee E12 confirmed that the facility failed to complete a comprehensive assessment after a significant change in condition for one of seven residents receiving hospice services (Resident R5). 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing services.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for three of fourteen residents (Residents R5, R18, and R202). Findings include: Review of the facility Skilled Nursing - Comprehensive Care plans dated August 2023, previously reviewed August 2022, indicated that A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs is developed for each resident. A review of Resident R5's clinical record indicated she was admitted to the facility on [DATE], with diagnoses that included constipation, muscle weakness, and cerebral palsy (group of disorders that affect movement, muscle tone, balance, and posture). A review of Resident R5's MDS dated [DATE], indicated the diagnosis were current. A review of Resident R5's care plan dated 11/14/23, failed to include a care plan for constipation. During an interview on 11/15/23, at 12:35 p.m. the Director of Nursing (DON) confirmed the facility failed to implement a care plan for constipation for Resident R5. A review of Resident R18's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses of dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), high blood pressure, and depression. A review of Resident R18's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 11/6/23, indicated that diagnoses remain current. A review of Resident R18's MDS assessment dated [DATE], Section V Care Area Assessment (CAA) Summary, Question V0200 revealed that the Psychotropic Drug use care area was triggered, and the care decision was made to include it on Resident R18's care plan. Review of the Resident R18's current care plan, failed to include goals and interventions related to Psychotropic drug use. During an interview on 11/17/23, at 11:20 a.m., the Director of Nursing confirmed the facility failed to develop and implement a comprehensive care plan to meet Resident R18's care needs for Psychotropic Drug use. A review of Resident R202's medical record revealed that the resident was readmitted to the facility on [DATE], with the diagnoses of heart failure, chronic kidney disease, weakness. anxiety disorder and history of falling. A review of Resident R202's physician orders revealed that on 11/15/23, the resident's order for a catheter was updated. The revised ordered indicated Resident R202 was prescribed a 16 French catheter with a 10 milliliter bulb. A review of Resident R202's resident centered care plan revealed that the facility failed to implement a care plan with goals and interventions for the use of a catheter. During an interview on 11/16/23, at 1:15 pm the Director of Nursing confirmed that the facility failed to implement a care plan addressing goals and interventions for Resident R202 being prescribed a catheter. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing services.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and records, and staff interviews, it was determined that the facility failed to implement the bowel regimen protocol and provide treatment as required for one of four residents reviewed (Resident R5). Findings: A review of the Bowel Protocol policy dated 8/23, indicated if a resident has not had a bowel movement in two days (six shifts), non-pharmacological interventions will be initiated on the morning of day three could include prune juice, bran, applesauce. If still no bowel movement, then administer 30ml of 400mg/5ml of Milk of Magnesia (over the counter treatment for constipation), then if still no bowel movement administer 10 mg of Dulcolax suppository (a laxative that stimulates bowel movement designed to be inserted into the rectum to dissolve). It was indicated if no bowel movement still, then administer a fleet enema 19g-7g/118ml (liquid medicine used to help you have a bowel movement that is inserted into the rectum). Then, if no bowel movement, contact physician for further orders. A review of the clinical record indicated that Resident R5 was admitted to the facility on [DATE], with diagnoses that included muscle weakness, cerebral palsy (a group of disorders that affect movement, muscle tone, balance, and posture), and constipation. A review of Resident R5's MDS dated [DATE], indicated the diagnosis were current. A review of Resident R5's care plan dated 11/14/23, failed to include a focus and interventions for constipation. A review of Resident R5's physician order dated 8/1/23, indicated to administer 17 gram MiraLAX (a laxative solution that increases the amount of water in the intestinal tract to stimulate bowel movements) by mouth, one time a day, for constipation. A review of Resident R5's physician order dated 8/1/23, indicated to administered two tablets of 50/8.6 mg tablet Docusate Sodium/Sennosides (laxative drug that can treat constipation) by mouth, two times a day, for constipation. A review of Resident R5's physician order dated 8/1/23, indicated to administer 30 ml of 400mg/5ml Milk of Magnesia by mouth, as needed, for constipation if no bowel movement in two days. A review of Resident R5's physician order dated 9/27/23, indicated to administer 0.5 tablets of 5/325mg Hydrocodone/APAP (opioid pain reliver that can cause constipation), by mouth, as needed for pain, twice daily. A review of Resident R5's physician order dated 10/6/23, indicated to administer 10mg Dulcolax suppository rectally, every 24 hours, as needed, for no bowel movement in two days. A review of Resident R5's October 2023 Medication Administration Record (MAR) indicated the resident was administered 0.5 tablets of 5/325mg Hydrocodone/APAP on 10/14/23, and 10/19/23. A review of Resident R5's Bowel Elimination report dated 11/14/23, indicated the resident did not have a bowel movement from 10/16/23, through 10/22/23, a total of seven days. A review of Resident R5's October 2023 MAR indicated the resident did not receive 30 ml of 400mg/5ml Milk of Magnesia after no bowel movement in two days, or 10 mg Dulcolax suppository after no bowel movement in two days from 10/18/23, through 10/22/23. A review of Resident R5's Bowel Elimination report dated 11/14/23, indicated the resident did not have a bowel movement from 11/11/23, through 11/13/23. A total of three days. A review of Resident R5's November 2023 MAR indicated the resident did not receive 30 ml of 400mg/5ml Milk of Magnesia after no bowel movement in two days or 10 mg Dulcolax suppository after no bowel movement in two days from 11/12/23, through 11/13/23. A review of Resident R5's Bowel Elimination report indicated the resident had a medium formed bowel movement on 11/14/23, at 3:26 a.m. During an observation on 11/14/23, at 10:08 a.m. Resident R5 appeared uncomfortable, and stated I just want to die. Resident R5 was turned and repositioned for a dressing change when Registered Nurse (RN) Employee E13 observed a very large firm bowel movement. Registered Nurse (RN) Employee E13 stated is was the size of a baby. During an interview on 11/15/23, at 9:52 a.m., Registered Nurse (RN) Employee E13 stated Resident R5 was on the bowel list for 11/14/23, because she didn't go for a few days. Registered Nurse (RN) Employee E13 stated she looked like she delivered a baby, I was surprised to see that, and indicated the formed stool weighed about three pounds. Registered Nurse (RN) Employee E13 stated she has a history of constipation and typically the aides will tell the nurses when she is having pellets. During an interview on 11/15/23, at 12:35 p.m. the Director of Nursing confirmed the facility to implement the bowel regimen protocol and provide treatment for constipation as required for one of four residents reviewed (Resident R5). 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and records, and a staff interview, it was determined that the facility failed to prevent pressure sore development and provide treatment as required for two of four residents (Resident R5 and R14). A review of the Dressing Change Policy policy dated 4/11/23, last reviewed 8/23, indicated it is the facility's policy to treat, measure, and track each wound individually. A review of the clinical record indicated that Resident R5 was admitted to the facility on [DATE], with diagnoses that included muscle weakness, cerebral palsy (group of disorders that affect movement, muscle tone, balance, and posture), and anemia (deficiency of healthy red blood cells in blood). A review of Resident R5's MDS dated [DATE], indicated the diagnosis were current. Section M: Skin Conditions indicated the resident was at risk for developing pressure ulcers and did not have any current pressure ulcers. A review of Resident R5's Braden Scale for Predicating Pressure Score Risk dated 11/22/22, indicated the resident was a high risk for developing pressure ulcers. A review of Resident R5's Braden Scale for Predicating Pressure Score Risk dated 2/21/23, indicated the resident was a high risk for developing pressure ulcers. A review of Resident R5's care plan dated 11/22/22, through 4/7/23, failed to include a focus and interventions to prevent pressure ulcers. A review of Resident R5's Skin Evaluation Form dated 4/8/23, indicated the resident developed a 6 cm x 1.5 cm Right Buttock Partial Thickness Moisture Associated Skin Damage. It was documented there was undermining (causes tissue damage under the skin's surface, forming a pocket or tunnel-like structure) on the wound edge. The facility failed to correctly identify Resident R5's pressure ulcer. There was no evidence the physician was notified. A review of Resident R5's progress note dated 4/14/23, entered by Physician Assistant, Employee E15 indicated the resident had a right buttock Full Thickness (damage extends below the epidermis and dermis (all layers of the skin) into the subcutaneous tissue or beyond (into muscle, bone, tendons, etc.) Moisture Associated Skin Damage that measured 7.3 cm x 8.1 cm x 0.1 cm. It was indicated there were shallow pink open areas. The wound increased in size and the facility staff failed to identify the resident's wound as a pressure ulcer. A review of Resident R5's progress note dated 4/17/23, indicated the resident Braden score was a 14, with shearing noted to buttocks, no other areas in the past year. A review of Resident R5's progress note dated 4/21/23, entered by Nurse Practitioner, Employee E16 indicated the resident had a right buttock Full Thickness Moisture Associated Skin Damage that measured 3.6cm x 2.9 cm x 0.2 cm with scant purple discoloration to inferior base. There was a small amount of serous drainage and the wound bed had 1-25% slough. It was indicated the peri wound skin exhibited excoriation (describes skin damage from mechanical injury.) Resident R5's skin condition failed to be correctly identified as a pressure ulcer. A review of Resident R5's progress note dated 4/28/23, entered by Physician Assistant, Employee E15 indicated the resident had a right buttock Full Thickness Moisture Associated Skin Damage that measured 2.8 cm x 3.8 cm x 0.1 cm. It was indicated the wound bed had slough. The peri wound skin exhibited excoriation and scarring. The facility staff failed to identify the resident's wound as a pressure ulcer. A review of Resident R5's progress note dated 5/5/23, entered by Physician Assistant, Employee E15 indicated the resident had a right buttock Full Thickness Moisture Associated Skin Damage that measured 3.5 cm x 4.6 cm x 0.1 cm. It was indicated a small amount of serous drainage was noted. The peri wound skin exhibited excoriation and scarring. The facility staff failed to identify the resident's wound as a pressure ulcer. A review of Resident R5's Skin Evaluation Form dated 5/12/23, entered by Licensed Practical Nurse (LPN), Employee E17 indicated the resident had a right buttock Deep Tissue Injury that measured 5.3 cm x 8 cm. It was indicated the cause of the skin condition was related to pressure. A review of Resident R5's OT-Therapist Progress and Discharge Summary dated 5/15/23, indicated the patient exhibits skin breakdown and discomfort on right buttock while lying in bed utilizing no special positioning equipment except for air mattress. A review of Resident R5's progress note dated 5/21/23, indicated the resident's air mattress was faulty and switched with a regular mattress. The vendor was notified the resident's air mattress needed to be repaired or replaced and it was indicated a technician would be in to fix. A review of Resident R5's progress note dated 5/26/23, indicated a technician was called and came into the facility to repair the resident's air mattress. The resident was without an air mattress from 5/21/23, though 5/26/23, a total of five days. Review of Resident R5's clinical record failed to include weekly skin assessments from 7/13/23, through 7/27/23. A review of Resident R5's progress note dated 10/5/23, indicated the resident tested positive for COVID-19 and was moved to isolation. A review of Resident R5's clinical record from 9/30/23, through 10/26/23, failed to include weekly skin assessments. Weekly skin assessment was not performed for 27 days. A review of Resident R5's clinical record failed to include weekly skin assessments from 10/28/23 through, 11/19/23. A total of 13 days. A review of Resident R5's physician order dated 11/7/23, indicated to cleanse buttocks with wound cleanser apply thin layer of raniers wound gel to entire wound bed, cover with gauze and abdominal pad dressing (ABD-used for large wounds or wounds that require high absorbency), then cover with elastic netting two times a day for wound care. During an observation of Resident R5's right buttock dressing change on 11/14/23 at 10:10 a.m., Registered Nurse Employee E9 failed to change the resident's dressing as ordered. RN Employee E9, failed to apply the gauze to the wound bed. During an interview on 11/14/23, at 10:33 a.m., the RN Employee E9 confirmed she failed to complete Resident R5's dressing change as ordered. During an interview on 11/15/23, at 9:17 a.m., Resident R5's POA was interviewed and stated things started to take a turn this spring from a pressure ulcer that developed shortly after the resident received a new wheelchair. During an interview on 11/15/23, at 9:52 a.m., Registered Nurse (RN) Employee E13, stated Resident R5 started to decline after she developed a wound to her buttocks. During an interview on 11/15/23, at 12:14 pm., LPN Employee E17 stated the resident's wound started as moisture associated skin damage, then all of a sudden it got worse. It was indicated one weekend there was a big open area, and LPN, Employee E17 stated Oh my God, what the heck, so we started cleaning it. It was indicated the physician assistant was consulted. During an interview on 11/16/23, at 2:05 p.m. the Director of Nursing (DON) confirmed if a resident wound is a full thickness wound then it is considered a pressure ulcer. The DON confirmed the facility failed to prevent pressure sore development and provide treatment as required for Resident R5. A review of the clinical record indicated that Resident R14 was admitted to the facility on [DATE], with diagnoses that included dementia, high blood pressure, and cancer. A review of Resident R14's MDS dated [DATE], indicated the diagnosis were current. Section M: Skin Conditions indicated the resident was at risk for developing pressure ulcers and did not have any current pressure ulcers. It was indicated the resident had Moisture Associated Skin Damage (MASD). A review of Resident R5's Braden Scale for Predicating Pressure Score Risk dated 8/2/23, indicated the resident was at risk for developing pressure ulcers. Review of Resident R14's progress note dated 8/2/23, indicated the resident had skin breakdown and excoriation on the coccyx. A review of Resident R14's care plan dated 8/2/23, indicated the resident had a documented pressure ulcer. Interventions indicated to monitor ulcer for signs of progression or declination, notify provider if no signs of improvement, provide s kin care per facility guidelines, and to provide wound care per treatment order. A review of Resident R14's progress note dated 8/3/23, indicated the resident was seen today for readmit skin assessment, resident has several ecchymosis scattered on upper and lower extremities as well as his right flank. Foam dressing intact to right back side, no open areas noted. A review of Resident R14's Braden Scale for Predicating Pressure Score Risk dated 8/9/23, indicated the resident was at risk for developing pressure ulcers. A review of Resident R14's Braden Scale for Predicating Pressure Score Risk dated 8/17/23, indicated the resident was a moderate risk for developing pressure ulcers. A review of Resident R14's Braden Scale for Predicating Pressure Score Risk dated 8/29/23, indicated the resident was a high risk for developing pressure ulcers. A review of Resident R14's progress note dated 8/29/23, indicated the resident had excoriation on the coccyx measuring 3 cm x 2 cm. A review of Resident R14's physician order dated 8/31/23, through 11/17/23, indicated to clean buttocks with soap and water, pat dry, then apply Triad wound paste and cover with a foam dressing for wound care. A review of Resident R14's progress note dated 9/8/23, indicated the resident had excoriation on the coccyx measuring 3 cm x 2 cm. A review of Resident R14's progress note dated 9/15/23, indicated the resident had excoriation on the coccyx measuring 3 cm x 2 cm. During an interview on 11/17/23, at 9:36 a.m., RN, Employee E18 confirmed weekly wound assessment were not completed for Resident R14 from 9/22/23, through 11/16/23, and the facility failed to provide pressure ulcer treatment for Resident R14. Review of a progress note dated 11/17/23, indicated resident ' s buttocks negative for any skin issue, no redness or open areas noted, the skin was pink. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.11(a) Resident care plan. 28 Pa. Code 211.12(d)(1) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review clinical records, and staff interviews it was determined that the facility failed to ensure that the physician order indicated a catheter size for a urinary catheter (insertion of a tube into the bladder to remove urine) for two of six residents (Residents R5, R15, and R103), and failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter as required for one of six residents (Resident R103). Findings include: Review of the clinical record indicated that Resident R5 was admitted to the facility on [DATE], with diagnoses that included muscle weakness, cerebral palsy (a group of disorders that affect movement, muscle tone, balance, and posture), and anemia (deficiency of healthy red blood cells in blood). A review of Resident R5's Minimum Data Set Assessment (MDS, periodic assessment of resident care needs) dated 4/5/23, indicated the diagnosis were current. A review of Resident R5's physician order dated 5/26/23, indicated to change catheter as needed for blockage or leakage. A further review of Resident R5's physician orders from 5/26/23, failed to include an order for the size catheter. During an interview on 11/15/23, at 2:10 p.m. the Director of Nursing (DON) confirmed the facility failed ensure a catheter size was included in the physician order for Resident R5. Review of admission record indicated that Resident R15 was admitted on [DATE]. Review of Resident R15's Minimum Data Set Assessment (MDS, periodic assessment of resident care needs) dated 113/23, indicated diagnoses of benign prostatic hyperplasia (enlarged prostate), obstructive uropathy (restriction in the flow of urine), and high blood pressure. Section H - Bladder and Bowel indicated the utilization of an indwelling catheter. Review of Resident R15 's physician order dated 8/20/23 indicated to change foley catheter every 30 days but did not have a physician's order regarding the size of the foley catheter and balloon. Review of admission record indicated that Resident R103 was admitted on [DATE]. Review of Resident R103's MDS dated [DATE], indicated diagnoses of benign prostatic hyperplasia, obstructive uropathy, and weakness. Section H - Bladder and Bowel indicated the utilization of an indwelling catheter. Review of Resident R103's physician order dated 1/23/23 indicated for resident to have a foley catheter but did not have a physician's order regarding the size of the foley catheter and balloon. During an observation on 11/14/23, at 10:53 a.m. Resident R103 was in bed, with his urinary drainage bag hanging on the bed with no privacy cover. During an interview on 11/15/23, at 11:50 a.m. Registered Nurse (RN) Employee E13 was asked where she would find information on what size catheter and balloon to use on a resident she replied I don't usually see that information. I just use whatever we have. During an interview on 11/15/23, at 2:14 p.m., the Director of Nursing confirmed the facility failed to ensure that the physician order indicated a catheter size for the use urinary catheter and use of privacy bag as required for Resident R15 and R103. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa code: 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical record, and staff interview, it was determined that the facility failed to ensure that proper hydration status was maintained by providing intravenous fluids as ordered for one of four residents (Resident R14). Findings include: Review of the clinical record revealed that Resident R14 was admitted to the facility on [DATE]. Review of Resident 14's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 11/3/23, indicated diagnoses of prostate cancer, dementia (neuro-cognitive disorder impacting reasoning, judgment, and memory), and high blood pressure. Review of clinical records revealed a physician's order dated 10/23/23, for sodium chloride intravenous (IV- in the vein) solution 0.45% with 20 mEq (milliequivalent) potassium (a solution used to supply water, salt and potassium) at 60 milliliters per hour every shift for dehydration to be administered from 10/23/23 on night shift until 10/25/23 on night shift. Review of Resident R14 's progress note dated 10/25/23, at 22:26 (10:26 p.m.), stated the following: During change of shift report was informed that IV fluids had been completed. During med (medication) pass had noticed that order for IV was to run until 9:30 pm, checked chart to see if this was in error, but no new order to discontinue early, contacted CRNP (Certified Registered Nurse Practitioner) and she was in agreement that IV fluids were to run until original time frame. No (prescribed IV solution) in building as IV taken down and discarded on 7-3 shift. Pharmacy alerted of need for IV fluids but no timetable of said fluids would arrive. CRNP then ordered IV fluids to be discontinued and keep IV and assure labs to be done in a.m. Review of Resident R14 's medication record revealed that resident received IV fluids as ordered on daylight shift on 10/25/23, but did not receive IV fluids on evening shift or night shift as ordered. During an interview on 11/17/23, at 1:22 p.m. Director of Nursing stated that there was no reason that the IV treatment should have been removed and confirmed that the facility failed to ensure proper hydration status was maintained by providing intravenous fluids as ordered. 28 Pa. Code: 201.18(b)(1)(e)(1) Management 28 Pa. Code: 201.12(d)(1)(3)(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy clinical record and resident and staff interview it was determined that the facility failed to provide medically related social services to one of seven residents reviewed (Resident R5). Findings include: Review of facility documentation Job Description for a social worker, indicated it is the duty of the social worker to respond to each resident social needs from the time of admission throughout the resident's stay, collaborating with other staff and professionals both in and outside the facility in developing and implementing coordinated individualized plan of care and supportive services. It was indicated it is the social worker responsibility to respond to the needs of the resident and family. It stated the social work duty is to assist residents and families with end of life decision making and provide educational materials, answer questions, and assist with making hospice referral. A review of the clinical record indicated that Resident R5 was admitted to the facility on [DATE], with diagnoses that included muscle weakness, cerebral palsy (a group of disorders that affect movement, muscle tone, balance, and posture), and anemia (deficiency of healthy red blood cells in blood). A review of Resident R5's MDS dated [DATE], indicated the diagnosis were current. Review of the Resident's progress notes dated 6/30/23, indicated a referral to hospice was made and facility staff spoke with a hospice provider and was told they cannot take resident with a wound vac. It was indicated that the facility will look for other hospice providers that will next week. If not, plan is to plan palliative care and place on hospice once wound vac complete. Review of Resident R5's progress note dated 7/3/23, entered by Licensed Practical Nurse (LPN) Employee E20 indicated the resident was awaiting hospice consult, once Hospice accepts patient, discontinue wound vac. Review of Resident R5's progress note dated 7/14/23, indicated Social Worker, Employee E4 spoke with the resident's POA (power of attorney) who was inquiring again about hospice. Social Worker Employee E4 informed the POA that hospice will not accept her while she has a wound vac. It was indicated the resident's power of attorney (POA- a legal authorization that gives a designated person the power to act for someone else) requests hospice is notified once the wound vac is discontinued. During an interview on 11/13/23, at 10:41 a.m., Resident R5's brother stated hospice was not able to take the resident if she had a wound vac. During an interview on 11/15/23, at 9:14 a.m., Resident R5's POA indicated Social Worker Employee E4 informed her that hospice would not take the resident because of her wound vac. During an interview on 11/16/23, at 11:50 a.m. Social Worker Employee E4 stated I did reach out to other hospice providers. Social Worker, Employee E4 stated she asked a hospice nurse that came to the facility from a different hospice provider and asked a hospice aide in passing. Social Worker Employee E4 was unable to provide any documented evidence that she reached out to hospice providers to see if they would accept Resident R5 with her wound vac. She indicated there was no reason why we didn't reach out to other hospice providers. Social Worker Employee E4 confirmed that the facility failed to provide medically related social services to one of seven residents reviewed (Resident R5). 28 Pa. Code 211.16 (a) Social services. 28 Pa. Code 211.5 (h)Clinical records

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on review of facility policies, observations and staff interview, it was determined that the facility failed to ensure that outdated biologicals were discarded in one of two medication rooms (Second Floor), and to accurately date open medications for one of four medications carts (Second floor North-East medication cart). Findings include: The facility Storage of medications policy last reviewed 8/2023, indicated that outdated medications will be removed from inventory, and that medications and biologicals are stored safely, securely and properly. During an observation on 11/14/23, at 11:50 a.m. in the Second Floor medication room with Licensed Practical Nurse (LPN) Employee E6 indicated the following: Dextrose 5% ( a solution of water and sugar adminstered via intravenous (IV) -in the vein) with an expiration date of May 2023 Central Line Tray ( used for aseptic dressing removal, cleaning and prepping of IV sites) with an expiration date of April 2023 During an interview on 11/14/23, at 11:50 a.m., Licensed Practical Nurse (LPN) Employee E6 confirmed that the facility failed to ensure that outdated biologicals were discarded. During observations on 11/15/23, at 10:09 a.m. on the Second floor with Licensed Practical Nurse (LPN) Employee E6, review of the Second floor North-East Medication cart indicated the following: Resident R115 Echinacia 400 mg (medication for immune health) found open and without an open date. Resident R11 Diclofenac Sodium Topical Gel for pain relief, found open and without an open date. Resident R65 Morphine 0.125ml/ sublingually every 4 hours as needed for pain, open and without an open date. During an interview on 11/15/23, at 10:09 a.m. Licensed Practical Nurse (LPN) Employee E6 confirmed that the facility failed to accurately date open medications for the Second floor medication cart as required. 28 Pa. Code: 211.9 (g)(h)(i) Pharmacy 28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing Services.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to obtain a physician order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for three of seven residents (Resident R5, R80, and R103). 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 2023, indicated the following instructions for Section O, Special Treatment, Procedures, and Programs: Facilities may code treatments, procedures, and programs that the resident performed themselves independently or after set-up by facility staff. Check all treatments, procedures, and programs received or performed by the resident after admission/entry or reentry to the facility and within the 14-day lookback period. Section O0100K Hospice care; Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related condition. Review of the facility Skilled Nursing - Comprehensive Care plans dated August 2023, previously reviewed August 2022, indicated that A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs is developed for each resident. Review of the facility's Nursing-Hospice Program dated 3/15/23, last reviewed 8/23, indicated the facility contracts hospice services for residents who wish to participate in such programs. A review of the clinical record indicated that Resident R5 was admitted to the facility on [DATE], with diagnoses that included muscle weakness, cerebral palsy, and anemia. A review of Resident R5's MDS dated [DATE], indicated the diagnosis were current. A review of Resident R5's physician orders dated 8/29/23, indicated the resident was admitted to hospice. A review of Resident R5's MDS dated [DATE], indicated the resident was on hospice. A review of Resident R5's care plan dated 11/15/23, failed to include a focus or interventions for hospice services. During an interview on 11/15/23, at 1:32 p.m., Registered Nurse, Employee E21 confirmed the facility failed to develop a hospice care plan for Resident R5. A review of Resident R80's clinical record indicated that he was admitted [DATE], with diagnoses that included neurocognitive disorder with Lewy bodies (a progressive dementia that results from protein deposits in nerve cells of brain. It affects movement, thinking skills, mood, memory, and behavior), heart disease, and high blood pressure. A review of Resident R80's Quarterly MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 8/21/23, indicated that diagnoses remain current. A further review of Resident R80's MDS dated [DATE], Section O, Special Treatments, Procedures, and Programs, Question O0100K: Hospice care was triggered, identifying service was provided While a Resident within the last 14 days. A review of current active physician orders for Resident R80, indicated that on 11/17/22, Resident arrived to [NAME] previously admitted to Hospice 2/22/22. A review of Resident R80's current comprehensive care plan failed to indicate a plan of care by the facility for hospice care goals and interventions, to include coordination of hospice services. During an interview on 11/16/23, at 1:00 p.m., Resident Nurse Assessment Coordinator (RNAC) Employee E12 confirmed that facility failed to implement a hospice plan of care for Resident R80. A review of Resident R103's clinical record indicated that he was admitted on [DATE], with diagnoses that included Review of Resident R103's , indicated diagnoses of benign prostatic hyperplasia (enlarged prostate), obstructive uropathy (restriction in the flow of urine), and weakness. A review of Resident R103's MDS assessment dated [DATE], indicated that diagnoses remain current. A further review of Resident R103's MDS dated [DATE], Section O, Special Treatments, Procedures, and Programs, Question O0100K: Hospice care was triggered, identifying service was provided While a Resident within the last 14 days. A review of current active physician orders for Resident R103, indicated that he was ordered hospice services on 5/29/23. A review of Resident R103's current comprehensive care plan failed to indicate a plan of care by the facility for hospice care goals and interventions, to include coordination of hospice services. During an interview on 11/17/23, at 12:28 p.m., Licensed Practical Nurse (LPN) Employee E14 confirmed that facility failed to implement a hospice plan of care for Resident R103. 28 Pa. Code 211.2(a) Physician services 28 Pa. Code 211.11(d) Resident care plan

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that a pneumococcal immunization was offered to one of five residents (Resident R48). Findings include: Review of the facility policy Infection Prevention and Control Program dated August 2023, indicated that the pneumococcal vaccination will be offered upon admission. Review of the admission Record indicated that Resident R48 was admitted to the facility on [DATE]. Review of Minimum Data Set (MDS-periodic assessment of care needs) dated 8/25/23, included diagnoses of high blood pressure, diabetes, and weakness. Section O0300 Pneumococcal Vaccine indicated Resident R48 was not offered the pneumonia vaccination. During an interview on 11//17/23, at 11:22 a.m. the Director of Nursing confirmed that the facility failed to make certain that a resident was assessed for and offered pneumococcal immunization for one of five residents. 28 Pa. Code 211.5(f) Clinical records

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected multiple residents

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Based on a review of facility employee personnel files, documents and staff interviews it was determined that the facility failed to employ a qualified Director of Dining Services (DDS) to manage the daily operations of the Dietary Department for 11 of 11 months. (1/23 through 11/23). Findings include: A review of the job description entitled Director of Dining Services revealed that the essential duties of the position include identifies and suggests innovative approaches and helps implement performance improvement opportunities. Education and experience requirements include Bachelor's degree preferred, or a minimum of two years related experience and training or equivalent combination of education and experience. Certification requirements include ServSafe Certification, Certified Dining Manager Certification or must obtain within one year of actively working as the Director of Dining Services. During an interview on 11/13/23, at 9:00 am Director of Dining Services (DDS) Employee E1 indicated that she has held the position of DDS since August 2022. Her certification credentials included ServSafe Manager Certification. A review of DDS Employee E1 personnel file revealed evidence that DDS Employee E1 failed to meet the requirements for the Director of Dining Services position in education, experience, and certification. A review of DDS Employee E1's Annual Evaluation dated 2/28/23 indicated that DDS Employee E1's career goal is to obtain her Certified Dietary Manager certification. Comments completed by DDS Employee E1 in response to describing her development concerns included the following: I do feel like I may not had enough 'training' for this role. My predecessor was here for my first few days but didn't really show me much. Overall comments completed by DDS Employee E1 were as follows: When I applied for this position, I really thought it was a long shot. During an interview on 11/17/23 at 9:40 am the Nursing Home Administrator (NHA) confirmed that the facility failed to provide documented evidence that DDS Employee E1 met the qualifications for the position of Director of Dining Services. She further confirmed that although the facility has provided support to learn the position this support failed to DDS Employee E1's career goal of obtaining a Certified Dietary Manager certification. The NHA confirmed that the facility failed to employ a qualified Director of Dining Services to manage the daily operations of the Dietary Department. Pa Code: 211.6(c)(d) Dietary Services

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on a review of facility policies, observations and staff interviews, it was determined that the facility failed to cover, label and date food products, properly dispose of contaminated food products, maintain the kitchen in a clean and sanitary manner, and properly wash and sanitize equipment in the Main Kitchen (Main Kitchen). Findings include: A review of facility policy Dietary' Food Receiving and Storage dated 8/23, indicated that foods shall be received and stored in a manner that complies with safe food handling practices. Foods will be covered, labeled and dated. Foods will be stored using a first in first out system. A review of facility policy Dietary- Refrigerators and Freezers dated 8/23, indicated that that all food products will be rotated according to expiration dates. Expiration dates include receiving dates and use by dates. Use by dates will be indicated on all prepared foods and food products that have been opened, A review of facility policy Dietary - Sanitation dated 8/23, indicated the food service area will be maintained in a clean and sanitary manner. Areas will be kept clean and in good repair free from open seams, cracks and chipped area that may affect their proper cleaning, manual equipment sanitation will follow manufacture guidelines, dish machines will be operated according to specifications including proper water temperatures for washing (150°F minimum) and final rinsing (160°F minimum) of equipment. During an observation of the Main Kitchen on 11/13/23, at 9:25 am the following was observed: * the kitchen floor throughout the Main Kitchen areas was heavily soiled with a build up of dirt and grime. * the kitchen flooring contained cracked seams, chipped areas and areas where the flooring tile was cracked and missing creating uneven surfaces that prevented proper cleaning. * the baker reach in refrigerator contained an undated opened container of liquid eggs * the freezer contained a pan of sausage patties that was uncovered, unlabeled and undated * the trayline quad refrigerator contained an undated, opened carton of 2% milk * the storeroom contained a package of bowtie noodles and a package of egg noodles that were undated * nine individual serving containers of cereal were observed on the storeroom floor at 9:50 am. Further observation at 10:00 am revealed that the containers had been removed from the floor. A dietary staff member confirmed that she placed the containers back in the box and failed to properly discard the contaminated containers. * thermal covers covering two trayline steamtables contained ripped and torn fabric, * stored in the main kitchen area was a soiled bin of rock salt used for snow removal. The bin was labeled with only the word salt During an interview on 11/13/23, at 10:15 am Director of Dining Services Employee E1 confirmed that the facility failed to maintain the kitchen in a clean and sanitary manner, properly label, date and store food products, properly maintain equipment in good repair, properly dispose contaminated food products and properly store non food products away from food production areas. During an observation on 11/15/23, at 9:00 am the Assistant Director of dining Service Employee E2 conducted a test of the chemical strength for the sanitizing solution in the three compartment manual ware washing sink. He utilized a test strip that he obtained from a vial of test strips. When comparing the strip to the color guide he was uncertain that the value obtained was with in the compliance range for the proper chemical strength. A review of the facility's dish machine temperature log on 11/15/23, revealed that the facility failed to record the dish machine temperatures prior to the start of breakfast ware washing cycle. During an observation on 11/15/23, at 9:10 am it was revealed that the facility had begun to wash equipment used during the breakfast meal. Director of Dining Services Employee E1 stated that she does not always complete a test strip monitor correctly when it was requested that she verify the final rinse temperature by running a test strip through the dish machine. The test strip revealed that the final rinse temperature failed to meet the 160°F requirement. During an interview on 11/15/23, at 10:00 am the Director of Dining Services Employee E1 confirmed that the dish machine failed properly maintain a final rinse temperature of a minimum of 160°F as required to sanitize equipment. During an interview on 11/15/23, at 11:15 am Contracted Vendor Representative confirmed that the facility failed to utilize the proper test strips to test the chemical concentration of sanitizing solution in the three compartment manual ware washing sink. Pa Code:211.6(c)(d) Dietary Services

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected most or all residents

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Based on a review of facility policies, observations, and staff interviews it was determined that the facility failed to properly dispose of refuse to prevent the potential infestation of rodents and insects for three of three refuse disposal containers (recycle bin, furniture and equipment dumpster, and compactor unit). Findings include: A review of facility policy Dietary- Food Related Garbage and Rubbish dated 8/23, indicated that garbage and rubbish will be disposed of in accordance with current state laws regulating such matters. Garbage and rubbish will be stored in a manner that is inaccessible to vermin. Outside dumpsters will be kept closed and free of surrounding litter. During an observation on 11/13/23, at 9:10 am the following was revealed: * the lids on the recycle dumpster were open. * the dumpster used for the disposal of furniture and equipment was uncovered and contained two bags of garbage and several disposable food containers and a pizza box. * the compactor unit was uncovered and contained bags of garbage that had not been compacted. The compactor unit was open and compacted garbage was accessible to rodents and insects. During an observation of the compactor unit on 11/13/23, at 9:15 am it was revealed that the garbage compacted into the receptacle remained uncovered and accessible to rodent and insect activity after the compactor had completed compaction of the garbage. During an interview on 11/13/23, at 9:21 am Director of Environmental Services Employee E10 confirmed that the facility failed to properly dispose of refuse. Pa Code: 207.2(a) Administrator's Responsibility

Feb 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected multiple residents

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Based on review of facility policy, observations, resident interviews, call bell audits, and staff interviews it was determined the facility failed to provide a reasonable accommodation to resident needs in call bell response times for five of seven residents (Resident R1, R2, R3, R4, and R5). Findings include: Review of Nursing assistant (NA) job description indicated that one of the NA's essential duties and responsibility is to answer call lights (an alert to staff the resident needs assistance) promptly. Review of Resident Incident Details Report (indicates the date and time a call bell is engaged and the time it is answered) for January 2023 and February 2023 revealed the following: Resident R1's record indicated on: 1/20/23, at 10:51 a.m. the call bell was engaged and not answered for 22 minutes and 39 seconds. 1/20/23, at 11:26 a.m. the call bell was engaged and not answered for 46 minutes and 35 seconds. 1/22/23, at 11:48 a.m. the call bell was engaged and not answered for 21 minutes and 28 seconds. 2/8/23, at 5:30 p.m. the call bell was engaged and not answered for 17 minutes and two seconds. Resident R2's record indicated on: 1/16/23, at 9:31 a.m. the call bell was engaged and not answered for 20 minutes and 24 seconds. 1/18/23, at 9:20 a.m. the call bell was engaged and not answered for 33 minutes and six seconds. 1/21/23, at 1:21 p.m. the call bell was engaged and not answered for 43 minutes and 27 seconds. 1/22/23, at 1:59 p.m. the call bell was engaged and not answered for 21 minutes and 47 seconds. 2/5/23, at 9:19 a.m. the call bell was engaged and not answered for 15 minutes and 47 seconds. 2/6/23, at 8:06 a.m. the call bell was engaged and not answered for 15 minutes and 49 seconds. 2/11/23, at 2:15 p.m. the call bell was engaged and not answered for 27 minutes and 35 seconds. Resident R3's record indicated on: 2/7/23, at 12:41 p.m. the call bell was engaged and not answered for 18 minutes and 25 seconds. Resident R4's record indicated on: 1/15/23, at 10:20 a.m. the call bell was engaged and not answered for 29 minutes and four seconds. 1/16/23, at 8:17 a.m. the call bell was engaged and not answered for 16 minutes and 43 seconds. 1/22/23, at 11:27 a.m. the call bell was engaged and not answered for 17 minutes and 21 seconds. Resident R5's record indicated on: 1/16/23, at 2:50 p.m. the call bell was engaged and not answered for 20 minutes and 11 seconds. 1/18/23, at 8:17 a.m. the call bell was engaged and not answered for 17 minutes and 46 seconds. 2/5/23, at 7:01 a.m. the call bell was engaged and not answered for 33 minutes and 13 seconds. 2/5/23, at 2:51 p.m. the call bell was engaged and not answered for 31 minutes and 22 seconds. Interview on 1/11/22, at 2:30 p.m. Grievance Official Employee E1 confirmed the facility failed to provide a reasonable accommodation to resident needs in call bell response times for five of seven residents (Resident R1, R2, R3, R4, and R5). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. 28 Pa. Code 201.29(j) Resident Rights

Dec 2022 9 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations and staff interview, it was determined that the facility failed to provide resident dignity during dining services for three of 18 residents (Resident R105, R130 and R136). Findings include: Review of the facility policy Feeding Guidelines last reviewed August 2022, indicated that residents that require assistance are encouraged to eat and be assisted when needed. Assure the meal being served is accurate and provided in dignified manner. During an observation of the lunch meal service on 12/13/22, from 11:45 a.m. through 12:30 p.m., on the [NAME] Memory Impaired nursing unit, East dining room, the following occurred: Resident R130, R105 and R136 were seated at a table. Resident R130's meal was placed in front of her at 11:43 a.m., another resident at another table was provided their meal. At 11:55 a.m., Resident R105's meal was placed in front of her, then Resident R136. Residents R130, R105, and R136, were not being assisted with their meals until all other 15 residents were served at 12:30 p.m., one half hour after meals were placed in front of them. Review of the Day Planner (sheet available for staff indicating the care needed for residents) indicated that Resident's R130, R105, and R136, were all identified as staff assisted feeds. During an interview on 12/13/22 at 12:33 p.m., the Director of Nursing confirmed that Residents R130, R105 and R136 did not receive a dignified dining experience. 28 Pa. Code: 201.29(j) Resident rights. 28 Pa. Code: 211.10(a)(b)(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(5) Nursing services.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected 1 resident

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Based on review of facility policy, resident council meeting minutes, group and staff interview, it was determined that the facility failed to demonstrate their response to resident concern and grievances identified during Resident Council Meeting for seven of 11 months (April, May, June, July, August, September, and October of 2022). Findings include: Review of facility policy Grievance Policy dated August 2022, indicated the facility will make certain prompt efforts to resolve all grievances that a resident may have and to assure that the facility actively seeks a resolution. The policy also defines the duties of the Grievance Officer including issuing written grievance decisions to the resident. A review of the facility Resident Council Meeting minutes revealed concerns the residents voiced in reference to cold and late food for the moths of April, May, June, July, September, and October 2022. A review of the facility Resident Council Meeting minutes revealed concerns the residents voiced in reference to staff being noisy in the hallways in the evenings for the months of May, June, August, September, and October 2022. A review of the facility Resident Council Meeting minutes revealed concerns the residents voiced in reference to clothing being shrunk or ruined for the months of August and September 2022. During a group interview on 12/13/22 from 11:00 a.m. to 11:45 a.m., nine of nine residents in the group confirmed that the food is cold being delivered for breakfast and dinner. Nine of nine residents confirmed that the hallways are noisy in the evening and that it has been addressed many times with no change. Residents in group have expressed concerns in previous resident council meetings and they feel that Administration is not communicating any follow up with concerns and they are not seeing any improvements. During an interview on 12/15/22 at 2:00 p.m., the Activities Coordinator E9 could not provide any documentation to demonstrate that there was a response to the resident concerns. During an interview on 12/16/22 at 1:00 p.m., the Director of Nursing confirmed the facility could not provide any documentation to demonstrate that there was a response to the resident concerns. 28 Pa. Code: 201.29 (1) Resident Rights. 28 Pa. Code: 211.12 (d)(3) Nursing Services. 28 Pa. Code: 201.18(e)(4) Management.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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Based on observations and resident group and staff interviews it was determined that the facility failed to have an accurate posted grievance procedure that was accessible to residents as required on three of three nursing floors (2nd, 3rd, and 4th floor nursing units). Findings include: A review of the facility policy Grievance Policy last reviewed August 2022, indicated residents have the right to file a grievance and a copy of the procedure to file a grievance with the forms will be prominently posted. The policy also does not name or designate the Grievance officer. During Resident Council interview on 12/13/22, at 11:00 a.m. all residents in the group voiced they were not aware of who the grievance official is or of the procedure for filing an grievance. During an observation on 12/13/22, at 1:00 p.m. on the Second-floor nursing unit, no grievance policy was posted in a prominent location or by the grievance box. During an observation on 12/3/19, at 1:30 p.m. of the Third-floor nursing unit, no grievance policy was posted in a prominent location or by the grievance box. During an observation on 12/3/19, at 2:00 p.m. on the Fourth-floor nursing unit, no grievance policy was posted in a prominent location or by the grievance box. During an interview on 12/05/19, at 11:20 a.m. Activities Coordinator Employee E9 confirmed the above observations, and that the facility failed to have a posted Grievance policy and procedure that contained all the required elements, and the Grievance Officer was not named on the Grievance policy 28 Pa Code 201.18(e) Management. 28 Pa Code 201.29(a) Resident Rights.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records, incident reports, employee statements and resident and staff interview, it was determined that the facility failed to ensure that a resident was free from neglect by not providing the necessary services, for one of five residents reviewed (Resident R98) and failed to ensure that a resident was free from potential neglect by not providing necessary services to prevent a fall with significant injury requiring transfer to hospital (Resident R22). Findings include: Review of the facility policy Corporate Compliance-Abuse Neglect dated August 2021, indicated the facility will not tolerate abuse, neglect and any suspected occurrence will have appropriate action taken. Residents must not be subjected to abuse/neglect by anyone including facility staff. Through elements of screening, training, prevention, identification, investigation, protection, and reporting, the facility will act to prevent abuse. Review of the facility policy Skilled Nursing-Lifting and Transferring Residents dated August 2021, indicated when physically assisting a resident, staff will use proper body mechanics Review of the clinical record indicated Resident R98 was admitted to the facility on [DATE], with diagnoses that included stroke and paralysis on the left side. Review of Resident R98's MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs) dated 7/22/2022, indicated that the diagnoses remained current. Resident R98 is alert and oriented and able to make needs known. Resident R98 requires assist of two persons for bed mobility. Review of Resident R98's care plan dated 7/11/2022, indicated that Resident R98 was at risk of falls due to weakness and deconditioning, and impaired safety awareness. Facility staff would provide Resident R98 with appropriate physical assistance for safe mobility. The care plan stated that the resident required help with turning and repositioning and bed mobility. Review of Resident R1's [NAME] (document that provides resident level of assistance for nursing staff) dated July 2022, indicated that the resident requires a physical assist of two persons. Review of an incident report dated 7/27/2022, indicated Resident R98 was rolled out of bed during care with nursing assistant (NA) Employee E1. Nurse Aide Employee E2 was present in the room during the incident. The resident sustained a laceration above the left eyebrow, nose and facial swelling, and pain in right leg and left arm. The CRNP (Certified Registered Nurse Practitioner) was notified and examined the resident and the resident was transferred to the hospital for evaluation. Review of a hospital report dated 7/27/22, indicated a laceration to the forehead that required sutures. Review of a CRNP note dated 7/29/22, indicated Resident R98 received five sutures to the forehead. Review of NA (Nursing Aide) Employee E1 Witness Statement dated 9/12/22, indicated that the Nurse Aide rolled Resident R98 and washed her backside and when straightening a pad to be placed under the resident, she rolled out of bed. NA Employee E1 was not available for interview. Nurse Aide Employee E2 was present but not at the bedside when the incident happened. Review of NA Employee E2 Witness Statement dated 7/27/22, indicated she observed Resident R98 on her side in the bed and rolled onto the floor and landed on her stomach. Nurse Aide Employee E2 indicated that she thought Nurse Aide Employee E1 was done with care when the roll out of bed occurred. During an interview on 12/15/22 at 9:00 a.m., Physical Therapy Rehabilitation Director Employee E3 confirmed that Resident R98 was an assist of two persons for bed mobility on 7/27/22. During an interview on 12/16/22 at 10:45 a.m., NA Employee E2 revealed NA Employee E1 had rolled Resident R98 in bed away from her without assistance of two persons which resulted in the resident falling out of bed requiring a transfer to the hospital and treatment for a laceration to the forehead. During an interview on 11/17/22, at 12:45 p.m. Resident R98 confirmed that on 7/27/22, she was rolled out of bed, and everyone came running and sent her to the hospital. Resident R98 was reluctant to provide any further information and stated It was an accident, and I am okay now. Review of NA Employee E1's employee transcript dated 5/20/22, indicated they had received education on proper body mechanics, and abuse/neglect. During an interview on 12/15/22, at 9:00 a.m. the Director of Nursing (DON) confirmed the facility's investigation of the incident found that it involved a substantiated neglect of service against NA Employee E1 as they did not use proper bed mobility as required for Resident R98 which resulted in a laceration to the forehead for Resident R98. Review of the clinical record indicated that Resident R22 was admitted to the facility on [DATE], with diagnoses that included dementia with behaviors, Alzheimer's disease, anxiety, osteoarthritis, repeated falls, and abnormal posture. Review of the MDS dated [DATE], indicated the diagnoses remained current. A physician order dated 6/11/18, indicated Resident R22 is combative with care. Review of Resident R22's day planner (a list of resident care needs the staff utilize daily) indicated resistive to care. Review of an incident report dated 1/9/22, indicated that Resident R22 had increased agitation with staff, was combative, and developed bruises on right and left forearms. There were no interventions put into place to prevent injury while resident is combative with care. Review of an incident report dated 6/4/22, indicated Resident R22 had developed a skin tear of her left forearm measuring 9 cm x 5 cm and skin could not be approximated (put back together). This wound required treatment for two months and did not heal. There were no interventions put into place to prevent injury during care. Review of a incident report dated 8/22/22, indicated that Resident R22 was combative with care, developed a skin tear after the NA was attempting to stop Resident R22 from falling. The wound required transfer to hospital and would require possible sutures. This wound was in the same area as the previous wound to the arm. Resident R22 developed an infection of this wound and required antibiotics from 9/9/22 through 9/13/22. The wound did not heal until 9/16/22. During an interview on 12/14/22 at 1:17 p.m, NA Employee E4 indicated that they were aware of Resident R22 becoming combative with care. While providing pm care on 8/22/22, the resident became combative, and NA Employee E4 attempted to prevent the resident from a fall. Resident R22 sustained a large skin tear to the left arm. During an interview on 12/16/22 at 10:46 a.m., the Director of Nursing (DON) confirmed that the facility neglected to include interventions to provide adequate care to prevent Resident R22 from injury when resistive to care. 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18(b)(1)(e)(1) Management. 28 Pa Code 201.29(a)(j) Resident rights. 28 Pa Code 211.12(d)(1)(5) Nursing services. 28 Pa Code 211.12(d)(3) Nursing services.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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Based on review of activity calendars, observations, staff interviews, and resident council interviews, it was determined that the facility failed to meet the activity needs for three of three nursing units (Second, Third and Fourth floors). Findings include: Resident Group meeting held on 12/13/22 at 11:00 a.m., revealed that nine out of nine residents agreed that the activities are not appropriate for them and that some activities scheduled do not happen. Resident group also stated unanimously that some activities are changed away from the scheduled activity. Review of the resident council meeting minutes for the previous 11 months, showed the resident council has asked in April, July, September and November for more adult activities and more groups. Review of the facility provided Activities Calendar on 12/14/22, for the second floor indicated cookie baking for the 11:00 a.m. activity. Observation of the 11:00 a.m. cookie baking showed seven residents sitting around a table with only one bowl. Each resident had to wait a turn to do one step in the mixing process. Review of the facility provided Activities Calendar on 12/14/22, for the fourth floor revealed the following: Reminiscing was indicated for the 11:00 a.m. and 2:00 p.m., activity. Observation of the 11:00 a.m. reminiscing activity on the fourth floor, showed residents watching television and no staff members for the activity. Observation of the 2:00 p.m. reminiscing activity on the fourth floor showed seven residents watching television in one hallway and six residents with one staff member having a conversation with one resident during the activity. Review of the facility provided Activities Calendar on 12/14/22, for the second floor indicated afternoon exercise scheduled for 2:30 p.m. Observation of the 2:30 p.m. afternoon exercise activity on the second floor showed the activity had been changed to a game called flip the pig (game where the resident rolls a plastic pig and gets a point for how it lands on its back, side, or legs). During this observation one resident who did attend the resident council meeting on 12/13/22 verbally stated this is what we was talking about when we said we need more adult activities. Interview on 12/15/22 at 12:00 p.m., Resident R122 stated that the facility does changes like the change from afternoon exercises to the pig game all the time and that the residents don't like the child games. During an interview on 12/15/22, at 1:00 p.m. the Activities Coordinator E9 was unable to provide a reason why the activities do not meet the needs or interests of the residents, why the activities are changed, and why the resident council request for more adult activities was not answered. Interview on 12/16/22 at 2:00 p.m. the Director of Nursing DON confirmed that the facility had failed to meet the activity needs and interests for three of three nursing units (Second, Third and Fourth floors). 28 Pa Code: 211.10(d) Resident care policies.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, incident report reviews, observations and staff interviews it was determined that the facility failed to ensure that the resident environment remained free from accident hazards on one of three nursing units ([NAME] Memory care nursing unit) and failed to provide adequate supervision and implement fall interventions to prevent accidents for one of two residents (Resident R86). Findings include: Review of the facility policy Adverse Events last reviewed August 2022, indicated that the facility will identify adverse events and conduct a thorough and timely investigation. A review of the facility policy Skilled Nursing-Fall Risk Assessment Policy reviewed August 2021 and August 2022, stated that residents will be assessed for fall risk, will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls, in the event of a fall, the facility will identify why the fall occurred, implement interventions post-fall, and the care plan will be revised as needed. During an observation on 12/14/22, at 9:20 a.m. a bottle of liquid was sitting at a desk in the back hall of the East wing of the [NAME] memory care nursing unit. During an interview on 12/14/22, at 9:22 a.m. Unit Manager Employee E6 confirmed the drink should not have been left unattended due to the potential for hazard for the residents of the [NAME] memory care unit. During an observation on 12/14/22, at 9:39 a.m., a housekeeping cart was left unattended with a bottle of cleaning solution unsecured in the East Hall of the [NAME] memory care nursing unit where three residents were seated nearby. During an interview on 12/14/22, at 9:39 a.m., Housekeeper Employee E7 confirmed that the unattended housekeeping cart and cleaner being unsecured had a potential for an accident on the [NAME] memory care unit. A review of the clinical record indicated Resident R86 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS-Resident Assessment and Care Screening) dated 9/28/22, included diagnoses of Non-Alzheimer's Dementia, weakness, unsteadiness on feet, and history of fracture of the right hip. Review of the MDS Section G- Functional status revealed that Resident R86 required extensive assistance of two persons for toilet use, including transferring on and off the toilet. A review of the facility report Post Fall Huddle Form indicates Resident R86 sustained a fall on 10/4/22, at 6:55 a.m. in the bathroom. Resident R86 was unable to describe what happened. The form identifies what new interventions could be added to the resident's plan of care to prevent reoccurrence? The form failed to identify any new interventions that were to be put in place as a result of the fall. A review of the facility report Post Fall Huddle Form indicates Resident R86 sustained a fall on 10/8/22, at 3:10 p.m. in the bathroom. The form identifies what new interventions could be added to the resident's plan of care to prevent reoccurrence? states monitor in bathroom. A review of the facility Post Fall Huddle Form indicates Resident R86 sustained a fall on 12/8/22, at 6:25 p.m. in the bathroom. The form indicates Resident R86 had been put on the toilet. The form identified for what interventions could be added to resident's plan of care to prevent reoccurrence? Do not leave resident on the toilet unattended. A review of Resident R86's care plan on 12/17/22, indicated that Resident R86 was at risk of falls and required staff to provide assistance with all transfers. The interventions Monitor in bathroom and Do not leave resident on the toilet unattended were not added to the care plan. Review of the facility day planner (a log of individual resident care needs utilized by Nursing Assistants) dated 12/17/22, failed to identify any of the fall interventions listed above. During an interview on 12/17/22, at 1:33 p.m. the DON confirmed the facility failed to implement any measures to prevent reoccurrence of falls for Resident R86. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(1)(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on a review of facility policy, observations, and staff interviews, the facility failed to make certain medications were stored in a safe and secure manner for one of three medication carts (Second Floor Medication cart) and in one of three medication rooms (Third floor medication room). Findings include: Review of the facility policy Storage of Medications last reviewed on 3/1/22, indicated that all medications and biologicals are stored in a safe, secure, and properly following the manufacturer's recommendations or those of the supplier. Medication rooms, carts and medication supplies are locked when not in use or in direct view of persons with authorized access. All refrigerated medications are maintained at temperatures between 36 degrees and 46 degrees with a thermometer to allow temperature monitoring. Medication refrigerators will be clean and no accumulation of frost, foreign matter or soiled material. Medications are stored separate from food items. During an observation on 12/13//22, at 9:20 a.m., the second-floor medication cart was placed in the hallway left unsecured with potential for access of any passerby. Licensed Practical Nurse (LPN) Employee E5 was behind a curtain inside a resident room out of view of the cart. Observation also identified three pills in a dosage cup ready for administration sitting on top of this medication cart. These pills were identified as Tylenol 500 mg, Atenolol 25 mg, and Senna 8.6 mg. During an interview on 12/13//22, at 9:35 a.m., LPN Employee E5 confirmed that she had left the medication cart unlocked and out of view, with three medications in a dosage cup unsecured leaving access for any passerby. During an observation of the Third Floor Medication room there was two refrigerators in use. One was identified as resident refreshment refrigerator which had an opened undated container of applesauce. The freezer area was full of accumulated ice. the thermometer indicated a temperature of 50 degrees. The second refrigerator was identified as the medication refrigerator with ice accumulated in the back of the refrigerator. The thermometer was at 50 degrees. A can of sparkling soda was identified in with medications. During an interview on 12/16/22, at 9:00 a.m., Unit Manager Employee E8 confirmed the two refrigerators were not maintained and at proper temperatures and cleaned. 28 Pa. Code: 211.9(a)(1)(2)(g)(h)(k)(l)(1) Pharmacy services. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, facility manufacturer's manual, clinical record review, and staff interview, it was determined that the facility failed to make certain that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are investigated and reported to the administrator of the facility and to other officials for six of 10 residents (Resident R11, R17, R57, R84, R91, and R105). Findings include: Review of the facility policy Abuse/Neglect last reviewed August 2022, indicated the facility will first identify abuse/neglect, protect the alleged victim. The investigation team will direct the appropriate action including reporting to the appropriate agencies. Review of the [NAME] lift (mechanical lift used to transfer residents) manufacturer's manual indicated that residents be evaluated for use of the [NAME] lift for safety. Residents must have a risk assessment (an evaluation to identify potential hazards and analyze what could happen if hazard occurs). Review of the clinical record indicated that Resident R11 was admitted to the facility on [DATE], with diagnoses which included dementia with behaviors, stroke, multiple fractures from falls, and delirium. Review of the MDS(Minimum Data Set- a periodic assessment of resident care needs) dared 12/5/22, indicated the diagnoses remained current. Review of an incident report dated 11/23/22, indicated that Resident R11 had developed bruises of his left and right chest. Resident was not able to tell staff what happened. During an interview on 12/13/22, at 12:46 p.m., the Director of Nursing (DON) confirmed that the facility failed to identify, investigate and report the bruises as injuries of unknown origin. Review of the clinical record indicated that Resident R17 was admitted to the facility on [DATE], with diagnoses which included dementia, anxiety, falls, back pain and gait unsteadiness. Review of the MDS dated [DATE], indicated the diagnoses remained current. Review of an incident report dated 9/15/22, indicated that Resident R17 developed a contusion (bruise) of her right forehead with bruising of her right eyelid. The incident report did not include a full investigation of how bruising occurred or if resident R17 had fallen. Review of an incident report dated 10/9/22, indicated that Resident R17 had developed a dark purple bruise of her left forearm measuring 3.5 cm x 1.0 cm. The incident report did not include a full investigation as to how bruising occurred. During an interview on 12/12/22, at 12:16 p.m. the DON confirmed that the facility did not identify, investigate and report the bruises of unknown origin. Review of the clinical record indicated that R57 was admitted on [DATE], with diagnoses that included dementia, osteoporosis, and unsteadiness on feet. An MDS dated [DATE], indicated the diagnoses remained current. Review of an incident report dated 9/12/22, indicated that Resident R57 developed a skin tear to her right elbow. During an interview on 12/14/22, at 2:30 p.m. the DON confirmed that the skin tear was not identified, investigated to rule out potential abuse. Review of the clinical record indicated that Resident R84 was admitted to the facility on [DATE], with diagnoses which included dementia, repeated falls and heart disease. An MDS dated [DATE], indicated the diagnoses remained current. Review of a grievance report indicated that his daughter alleged neglect when Resident R84 was left in a soiled brief when the facility nurse aides stated they were waiting for the Hospice staff to provide care for the resident. During an interview on 12/13/22, at 2:18 p.m., the DON confirmed that the allegation was not fully investigated to rule out neglect. Review of an incident report dated 8/30/22, indicated that Resident R84 developed a skin tear of his contracted right arm while being transferred with the [NAME] lift. During an interview on 12/13/22, at 12:08 p.m., the DON confirmed that the incident was not investigated, identified, and/or reported to rule out potential for neglect. Review of the clinical record indicated that Resident R91 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease, panic disorder, anxiety, and muscle weakness. Review of the MDS dated [DATE], indicated the diagnoses remained current. Review of an incident report dated 11/28/22, indicated that Resident R91 developed a left arm skin tear which required a treatment while she was being put into bed using a [NAME] lift. The incident report did not include the name of staff assisting at the time and was incomplete. Review of the clinical record indicated that Resident R105 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease, Dementia, muscle weakness, osteoporosis, unsteadiness on feet. Review of the MDS dated [DATE], indicated the diagnoses remained current. Review of an incident report dated 4/7/22, indicated that Resident R105 developed a purple area to the inner corner of her left eye. The incident was not investigated, identified, and or reported to rule out abuse/neglect. Review of a incident report dated 11/29/22, indicated Resident R105 developed a bruise to her left forearm. The incident was not investigated, identified, and or reported to rule out abuse/neglect. During an interview on 12/15/22, at 10:52 a.m. the DON confirmed the above findings and that the facility failed to to make certain that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are investigated and reported to the administrator of the facility and to other officials for Residents R11, R17, R57, R84, R91, and R105. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

QAPI Program (Tag F0867)

Could have caused harm · This affected multiple residents

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Based on a review of the facility's policies, plans of corrections 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 make certain that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: A review of the facility policy Quality Assurance and Performance Improvement plan dated August 2021 and August 2022, indicated that the facility will develop a facility wide performance improvement program to evaluate resident care and performance of the organization and develop and implement plans for improvement to address deficiencies identified. The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) surveys ending December 3, 2021, revealed that the facility would maintain compliance with cited nursing home regulations. The results of the current survey ending December 16, 2022, identified repeated deficiencies related to making certain that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are investigated, and reported to the administrator of the facility and to other officials. The facility's plan of correction for a deficiency regarding investigating allegations of abuse and neglect, including injuries of unknown origin, cited during the survey ending 12/3/21, 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 F609, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding investigating and reporting allegations of potential abuse and neglect. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s). Review inspection reports carefully.
• 48 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• $11,200 in fines. Above average for Pennsylvania. Some compliance problems on record.
• Grade F (21/100). Below average facility with significant concerns.

Bottom line: Trust Score of 21/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Willows Of Presbyterian Senior's CMS Rating?

CMS assigns WILLOWS OF PRESBYTERIAN SENIOR an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Willows Of Presbyterian Senior Staffed?

CMS rates WILLOWS OF PRESBYTERIAN SENIOR's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 50%, compared to the Pennsylvania average of 46%.

What Have Inspectors Found at Willows Of Presbyterian Senior?

State health inspectors documented 48 deficiencies at WILLOWS OF PRESBYTERIAN SENIOR during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 45 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Willows Of Presbyterian Senior?

WILLOWS OF PRESBYTERIAN SENIOR is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 193 certified beds and approximately 166 residents (about 86% occupancy), it is a mid-sized facility located in OAKMONT, Pennsylvania.

How Does Willows Of Presbyterian Senior Compare to Other Pennsylvania Nursing Homes?

Compared to the 100 nursing homes in Pennsylvania, WILLOWS OF PRESBYTERIAN SENIOR's overall rating (1 stars) is below the state average of 3.0, staff turnover (50%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Willows Of Presbyterian Senior?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.

Is Willows Of Presbyterian Senior Safe?

Based on CMS inspection data, WILLOWS OF PRESBYTERIAN SENIOR has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Pennsylvania. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Willows Of Presbyterian Senior Stick Around?

WILLOWS OF PRESBYTERIAN SENIOR has a staff turnover rate of 50%, which is about average for Pennsylvania nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Willows Of Presbyterian Senior Ever Fined?

WILLOWS OF PRESBYTERIAN SENIOR has been fined $11,200 across 1 penalty action. This is below the Pennsylvania average of $33,191. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Willows Of Presbyterian Senior on Any Federal Watch List?

WILLOWS OF PRESBYTERIAN SENIOR is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 193
Avg. Residents: 166
Occupancy: 86.3%
Ownership: Non profit - Corporation
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
1 Immediate Jeopardy citation: -12
1 Actual Harm citation: -5
48 Deficiencies: -10
Fines ($11,200): -2
Final Score: 21/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 395713