Every finding on record at Allied Services Transitional Rehab Unit

Based on review of clinical records, review of facility documentation, and staff interviews, it was determined that the facility failed to develop and implement a baseline person-centered care plan within 48 hours of admission that addressed immediate clinical needs for one of one resident reviewed (Resident 52).Findings include:A review of the facility provided policy entitled Resident Comprehensive Care Plan last reviewed by the facility on October 25, 2025, indicated the facility will develop a comprehensive care plan, initiated on admission and reviewed after completion of each comprehensive assessment and quarterly assessment for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs. The objective of the care plan is to address residents' needs, strengths, and preferences and to attain the residents' highest practicable physical, mental, and psychosocial well-being. The policy indicated there will be 24-hour involvement in the Plan of Care. Resident needs, problems, and concerns will be updated by appropriate team members as frequently as necessary. A review of Resident 52's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included urinary retention (a condition in which the bladder is unable to fully empty urine), UTI (urinary tract infection, an infection in any part of the urinary system), and severe sepsis (occurs when one's immune system has a dangerous reaction to an infection and causes extensive inflammation throughout the body that can lead to tissue damage, organ failure and even death). Further clinical record review revealed a physician's order dated December 5, 2025, at 2:45 PM, to catheter (is a device that drains urine from the bladder into a collection bag outside of the body when one cannot urinate on their own and consists of a thin, flexible rubber or plastic tube that goes through the urethra into the bladder) care every shift for good hygiene and cleanse with soap and water, and to irrigate catheter for blockage as needed (PRN) with 30 ml NSS (normal saline solution). A review of a history and physical assessment completed by the facility's Certified Registered Nurse Practitioner (CRNP) dated December 5, 2025, at 7:33 PM, indicated Resident 52 was seen by urology (specialized in urinary conditions) while hospitalized and required a Foley catheter due to urinary retention. The facility was able to provide justification for the continued use of a Foley catheter. However, Resident 52's physician orders failed to reflect an order for the continued use of a Foley catheter for management of urinary retention. A review of Resident 52's person-centered plan of care that was initiated on December 5, 2025, and in place as baseline care plan, failed to develop a care plan that included the resident's need for a Foley catheter and indicate person-centered interventions for proper care and services required to safely and hygienically manage the presence of a catheter. The facility failed to ensure Resident 52's plan of care was fully developed to reflect the resident's need for use of a Foley catheter and develop individualized interventions for proper care and services required to manage the presence of a catheter. During interviews with the facility's Nursing Home Administrator (NHA) and Director of Nursing (DON) on December 11, 2025, at 10:50 AM, the above information was reviewed and confirmed. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa Code 211.12 (d)(3)(5) Nursing services. 28 Pa. Code 211.5(f)(iii) Medical records.

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to fully develop a person-centered comprehensive care plan to meet the individualized needs for one resident out of 8 sampled (Resident 21). Findings included: A review of the facility provided policy entitled Resident Comprehensive Care Plan last reviewed by the facility on October 25, 2025, indicated the facility will develop a comprehensive care plan, initiated on admission and reviewed after completion of each comprehensive assessment and quarterly assessment for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs. The objective of the care plan is to address residents' needs, strengths, and preferences and to attain the residents' highest practicable physical, mental, and psychosocial well-being. The policy indicated there will be 24-hour involvement in the Plan of Care. Resident needs, problems, and concerns will be updated by appropriate team members as frequently as necessary. A review of Resident 21's clinical record revealed Resident 21 was admitted to the facility on [DATE], with diagnoses including acute diastolic congestive heart failure (a condition where the heart is not able to pump blood and fluid builds up in the lungs and other areas of the body) and Circadian Rhythm Sleep Disorder (a condition that disrupts or affect ones natural sleep-wake cycle). A clinical record review of physician's orders dated December 1, 2025, revealed a physician's order for Melatonin (an over-the-counter pill commonly used to help individuals who have difficulty sleeping and used to adjust the body's internal clock to support sleep) 3 mg, one tablet every evening at bedtime for Resident 21's difficulty obtaining adequate rest and sleep. Further review of the clinical record revealed Resident 21's care plan did not include any information addressing the resident's lack of ability to get adequate rest and sleep. The absence of a resident centered care plan addressing Resident 21's inability to sleep contradicts the facility policy which identifies that any psychosocial needs as well as moods and behaviors will be incorporated into the comprehensive care plan. An interview with the Nursing Home Administrator (NHA) and Direct of Nursing (DON) on December 11, 2025, at 10:45 AM confirmed Resident 21's care plan did not reflect resident centered psychosocial and clinical needs nor was there 24-hour involvement in the care plan as the care plan lacked updated information. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa Code 211.12 (d)(3)(5) Nursing services. 28 Pa. Code 211.5(f)(iii) Medical records.

Based on clinical record review and staff interview, it was determined that the facility failed to complete and accurate Minimum Data Set (MDS) assessment for one of eight residents reviewed (Resident 21).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (dated October 2025) provides instructions and guidelines for completing the Minimum Data Set (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care). The RAI manual requires the MDS 3.0 assessment accurately reflects the resident's status. A registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals, and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. According to the RAI manual, Section I of the MDS emphasizes that active diagnoses are to be included on the assessment. Specifically, items in Section I code diseases or active diagnosis that have a direct relationship to the resident's current functional, cognitive, mood or behavior status, medical treatments, nursing monitoring, or risk of death. Active diagnosis guides the plan of care since one of the important MDS functions is to present an accurate picture of the resident's current health status according to the RAI manual. A review of Resident 21's clinical record revealed Resident 21 was admitted to the facility on [DATE], with diagnoses including acute diastolic congestive heart failure (a condition where the heart cannot pump blood and fluid builds up in the lungs and other areas of the body). Further clinical record review revealed a physician order dated December 1, 2025, for Melatonin 3 milligrams (mg) by mouth at bedtime. Melatonin is an over-the-counter medication commonly used to help regulate sleep by supporting the body's natural sleep-wake cycle. Review of the electronic medication administration record confirmed Resident 21 received Melatonin 3 mg each evening beginning December 1, 2025. Additional review of the clinical record revealed an admission diagnosis of Circadian Rhythm Sleep Disorder, active as of November 28, 2025. Circadian Rhythm Sleep Disorder is a condition in which an individual's internal biological clock is disrupted, resulting in difficulty falling asleep, staying asleep, or achieving adequate restorative sleep. This diagnosis was consistent with the ordered and administered medication to facilitate sleep for Resident 21. Review of Resident 21's admission MDS dated [DATE], revealed that Section I was signed as completed by the Registered Nurse Assessment Coordinator (RNAC) on December 8, 2025. The MDS did not include the active diagnosis of Circadian Rhythm Sleep Disorder. The omission of this diagnosis resulted in the MDS not accurately reflecting Resident 21's current medical treatments, specifically the use of medication to facilitate sleep, and did not accurately represent the resident's mood or behavior status as it related to the inability to attain adequate rest. Further clinical review of the admission MDS revealed all MDS sections were complete and signed by the RNAC as complete on December 9, 2025. Subsequently, the admission MDS was successfully transmitted to the database on December 10, 2025, according to the assessment history. The MDS completed on December 9, 2025, and submitted on December 10, 2025, did not accurately include Resident 21's current diagnosis related to current medical treatment and the resident's mood or behavior status, as required by the RAI manual to facilitate sleep as it relates to the ability to attain adequate rest. An interview conducted on December 11, 2025, at 10:45 AM with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the electronically submitted MDS did not include the diagnosis of Circadian Rhythm Sleep Disorder and therefore did not accurately represent Resident 21's medical treatments and mood or behavior status at the time of submission. An interview conducted on December 11, 2025, at 12:30 PM with the RNAC confirmed that the admission MDS was not coded accurately. 28 Pa Code 211.12 (d)(3)(5) Nursing services. 28 Pa. Code 211.5(f)(iii) Medical records.

Based on a review of clinical records, select facility policy, and staff interview, it was determined the facility failed thoroughly assess and timely implement treatments to an identified skin impairment for one resident out of 14 sampled residents (Resident 18). Findings included: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of a facility policy entitled Wound Management Pressure Reduction last reviewed by the facility on October 24, 2024, indicated that it was the policy of the facility to assess each resident's potential for skin breakdown based on clinical risk factors. On admission and readmission, a body check will be completed by the licensed nurse and documented on the Dermatological Evaluation form. The dermatological sheet will reflect the type of skin impairment and location, size, description, shape, drainage, odor, and color. A review of Resident 18's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included a left femur fracture (is a breakage in the thigh bone (femur), the longest, strongest and heaviest bone in the human body that usually requires surgical repair) with left artificial hip joint (a left artificial hip refers to a hip replacement surgery where a damaged hip joint is replaced with an artificial one made of metal, ceramic, and plastic to reduce pain and improve mobility), type II diabetes (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), and chronic kidney disease (is a condition characterized by a gradual loss of kidney function where in early stages can be show no symptoms and the disease progression occurs slowly over a period of time). A clinical record review revealed that a wound-skin healing record form was completed by the Director of Nursing (DON) on January 10, 2025, and signed on January 13, 2025, revealed that Resident 18 had a pressure injury identified as a suspected deep tissue injury [(DTI) The National Pressure Ulcer Advisory Panel (NPAUP) defines a deep tissue injury as a pressure-related injury to subcutaneous tissues under intact skin and initially appear like a deep bruise but subsequent progress and development into a Stage III or IV pressure ulcer] to the right heel, no measurements noted, described as red/purple. Resident 18's baseline plan of care that was initiated on January 11, 2025, identified that the resident was at risk for alteration in skin integrity related to immobility and skin breakdown as evidence by rash with a resident goal for the resident's skin integrity to be maintained as evidenced by no skin breakdown. Planned interventions included to administer wound treatment as ordered and assess and record details of wound and notify physician of any changes in wound condition. Further review of Resident 18's clinical record revealed a nurse's progress note completed by a Registered Nurse (RN) dated January 13, 2025, at 6:48 AM, that indicated the resident had a 3 by 3 cm blister on right heel. Skin prep applied and elevated off the bed. A review of physician's orders in Resident 18's clinical record revealed an order dated January 13, 2025, at 6:54 AM, to apply skin prep to bilateral heels every shift and elevate heels off the bed whenever in bed every shift for right heel blister/ left heel prevention for blister right heel and prevention left heel. Resident 18's clinical record failed to reveal that a RN performed a thorough assessment of the resident's noted DTI to her right heel and that a treatment was applied to the impaired area upon identification. The facility could not provide documented evidence that Resident 18's noted DTI to her right heel was measured and thoroughly assessed upon admission to the facility. Additionally, the facility could not provide documented evidence that a treatment was applied to the resident's right heel DTI upon initial identification. During an interview with the Director of Nursing (DON) on February 21, 2025, at 10:35 AM, confirmed that the facility failed to thoroughly assess Resident 18's right heel DTI upon admission and timely apply effective treatments for wound management. 8 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, controlled drug medication records, controlled drug shift count records, and staff interviews, it was determined the facility failed to implement procedures to promote accurate controlled medication records by not ensuring the completion of required narcotic shift counts on two of two medication carts observed. Findings include: A review of the facility's current policy titled Administration of Medication Schedule II-V Controlled Drugs, last reviewed on October 24, 2024, revealed that a physical inventory of controlled medications must be conducted at the end and beginning of each shift by two licensed nurses. The policy specifies that both the oncoming and off going nurses must view the medication together, validate the count, and document their verification with signatures. A review of the facility's Narcotic Count Sheets for January 2025 for the [NAME] Wing medication cart (located on the [NAME] Hall of the nursing unit) was conducted on February 19, 2025, at approximately 7:10 PM. The review revealed that on multiple occasions, either the oncoming or off going nurse failed to sign the sheet, indicating a lack of verification of the controlled drug count during shift change. Specifically, missing signatures were noted on the following dates: January 7, 2025 - Third shift off going nurse January 9, 2025 - Third shift oncoming nurse January 10, 2025 - Second shift oncoming nurse January 13, 2025 - Third shift oncoming nurse January 19, 2025 - Third shift oncoming nurse January 20, 2025 - Third shift oncoming and off going nurses January 31, 2025 - Third shift off going nurse A review of the Narcotic Count Sheets for February 2025 for the East Wing medication cart (located on the East Hall of the nursing unit) was conducted on February 19, 2025, at approximately 7:15 PM. Similar discrepancies were identified where the required shift count verification signatures were missing. Specifically, missing signatures were noted on: February 14, 2025 - Third shift off going nurse February 15, 2025 - Second shift oncoming nurse and third shift off going nurse February 19, 2025 - Third shift oncoming nurse During an interview on February 21, 2025, at approximately 3:00 PM, the Director of Nursing confirmed the facility failed to ensure consistent implementation of procedures to maintain accurate controlled drug records. 28 Pa. Code 211.19(a)(1)(k) Pharmacy services 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to ensure proper storage and adherence to expiration/use by dates for pharmaceutical products in one of one medication rooms observed. Findings include: Observations of the facility's medication room on [DATE], at approximately 10:35 AM revealed 38 Max Zero Needless connectors that expired May, 8, 2023, 11 Max Zero Needless connectors that expired [DATE], one 20 gauge needle safety infusion set that expired [DATE], two 20 gauge needle safety infusion sets that expired [DATE], two 22 gauge Autoguard BC winged IV catheters that expired [DATE], one 24 gauge Autoguard BC winged IV catheter that expired February 8, 2023, two 27 gauge disposable needles that expired [DATE], two 27 gauge disposable needles that expired [DATE], two IV starter kits that expired [DATE], and one IV starter kit that expired [DATE]. An interview with Employee 1 LPN (license practical nurse) on [DATE], at 10:44 AM confirmed the pharmacy supplies had expired and should have been discarded. During an interview with the Nursing Home Administrator on [DATE] at approximately 12:45 PM confirmed expired pharmacy products should have been removed from the medication room and discarded. 28 Pa. Code 211.9 (k) Pharmacy services

Based on observations, review of clinical records, select facility policies, and information submitted by the facility and staff interviews, it was determined that the facility failed to provide adequate staff supervision of a resident to monitor the resident's whereabouts and timely identify the resident's absence from the facility to assure prompt implementation of established procedures for a missing resident, which placed the resident in immediate jeopardy to her health and safety for one resident out of 12 residents sampled (Resident 18). Findings include: A review of the facility policy dated February 2017 entitled Wandering/Elopement revealed that It is the policy of the facility to ensure the safety and welfare of its residents, including those who are cognitively impaired or mental disturbed and are at risk for leaving the facility without regards to their own safety. According to the policy, on admission all residents will have their pictures taken for immediate positive identification in case of elopement and for positive identification for medication and treatment administration. On admission, readmission, quarterly, the elopement risk assessment will be completed on all residents. When a resident, who is identified as at risk to leave the facility unattended, cannot be located on the unit or any resident identified as missing from the facility, the following procedure will be followed: charge nurse will notify the unit manager or nursing supervisor on duty, on 3-11, 11-7, weekends and holidays, the nursing supervisor will initiate internal notifications, including security, administrator or designee to coordinate search efforts. The facility policy also indicated that if the time frame for this external and internal search exceeds 45 minutes and is unsuccessful, administration will report the incident to the police department with a complete description of the resident and what he/she was wearing (if known). The resident's family and/or responsible party will also be contacted, as well as the attending physician. A review of the clinical record revealed that Resident 18 was admitted to the facility on [DATE]. The resident's diagnoses included urinary tract infection, diabetes, and enterocolitis due to clostridium difficile (bacterial infection that causes diarrhea and inflammation of the colon). Review of Resident 18's Pre-Admission Screening completed by the facility on June 22, 2023, indicated that the resident required supervision with dressing of her upper extremities, required minimal staff assistance for lower extremity dressing and toileting. According to the screening, the resident's functional status as of June 22, 2023, indicated that the resident used a rollator walker for ambulation with minimal assistance of staff, and transferred with minimal assistance of staff. A review of Resident 18's Elopement Risk Evaluation dated June 23, 2023, indicated that the resident was not identified as an elopement risk. Social Service progress note dated June 26, 2023, indicated that Resident 18 was cognitively intact. Social Service progress noted dated June 28, 2023, indicated that Resident 18 requested discharge on Monday, July 3, 2023. According to the note, the resident requested discharge prior to the holiday so if there was any delay in her home health therapy, at least family would know her needs. The resident's family was to come in the facility for therapy to provide family training prior to discharge. Additionally, the resident declined to have her picture taken for her electronic medical record at that time. A review of information dated July 1, 2023, submitted by the facility revealed that Resident 18 was last seen in the facility by nursing staff at 8:51 a.m. on that date when she was provided morning care and medications. According to the initial facility report, at 12 noon, on July 1, 2023, Employee 3, registered nurse, identified that Resident 18 was no longer in the facility. Employee 3 called the resident's family which revealed that the resident's daughter who had been in earlier that morning, had taken the resident home. However, this account of the resident's absence was not accurate and it was later determined that Employee 3, RN did not identify the resident as missing from the facility until approximately 2 PM on July 1, 2023. Review of witness statement provided by Employee 1, nurse aide, dated July 1, 2023, revealed that from 8:30 a.m. until 9:00 a.m. she observed Resident 18 in the bathroom washing up at the sink. Employee 1 stated that she saw two visitors in the resident's room at 9:15 a.m. When Employee 1 went to perform vital signs on Resident 18 at 10:30 a.m., the resident was not in her room, and she reported it to the supervisor (Employee 3, registered nurse) and the resident's assigned nurse (Employee 2, licensed practical nurse). When Employee 1 delivered Resident 18's lunch tray at midday, the resident still wasn't in her room, and Employee 1 again reported to Employees 3, RN and Employee 2 that the resident was not in her room. Review of witness statement provided by Employee 2, licensed practical nurse, dated July 1, 2023, revealed that at 8:50 a.m., Resident 18 was administered her morning medications and was in the bathroom getting ready for the day. At 11:00 a.m. Employee 2 went into the resident's room to administer medication {perform blood sugar check}, but resident was not in her room. Employee 2 stated that she thought the resident was doing therapy. At 11:30 a.m. the resident still was not in her room. At 12:00 p.m. she thought Resident 18 was on the patio with family or in a visitation but forgot to sign out. Employee 2 searched the lounge, but the resident wasn't there. At 2:00 p.m. Resident 81 still was not in her room. Employee 2 stated that she went to look for the resident in the lounge, in the patio, and outside of the building, but was not successful in locating the resident. At that time, Employee 3 called the resident's family and realized the patient had been discharged without any knowledge of any nursing staff. Review of witness statement provided by Employee 3, registered nurse, dated July 1, 2023, revealed that Resident 18 was last seen at 8:51 a.m. in her bathroom washing up. At 9:30 a.m. Resident 18 was not in her room, television was on, and belongings were on overbed table, assumed resident was with therapy. At 10:30 a.m., the resident was not in her room. At 11:45 a.m. when staff delivered lunch tray, the resident was not in her room and the staff checked the dayroom. The resident was not in the dayroom and Employee 3 assumed she was on the patio with family. At 2:15 p.m. Resident 18 still was not in her room. The dayroom was checked again, the patio was checked, the floor perimeter was checked, and the sign-out book and chart were checked to see if resident had signed out. Employee 3 then called Resident 18's emergency contact number 2/ resident representative (daughter) who stated that she hadn't spoken to the resident in two days. At 2:30 p.m. Employee 3 called the resident's emergency contact number 2 (daughter) who stated that her mom is home. According to this daughter, the resident had called her and stated she wanted to go home, and she came and got her. At that time, the resident's physician, the Nursing Home Administrator, and Social Service were made aware that the resident had been missing from the facility and was home with family. The facility's report further noted that the resident and family were instructed to return to the facility for proper discharge instructions, education, and prescriptions. According to the report, the resident and family refused to return to the facility. The facility then considered the resident to have discharged against medical advice. The facility determined that the resident discharge appeared to be safe for a competent resident, but against medical advice. Interview conducted with Employee 1, nurse aide, on July 6, 2023, at 9:00 a.m. confirmed that she twice reported to both the nursing supervisor and the resident's assigned nurse that Resident 18 was not present in her room during observations at 10:30 a.m. and at time of lunch tray delivery, approximately 11:45 a.m. Interview was unable to be conducted with Employee 2, LPN. The surveyor called Employee 2 on July 6, 2023, at 10:30 a.m., left a message with no return call received. Interview conducted with Employee 3, RN, on July 6, 2023, at approximately 11:30 a.m. confirmed that she did not initiate a timely search when Resident 18 was identified as missing from the nursing unit and failed to timely notify facility administration and security that the resident was missing. Employee 3 confirmed that she failed to promptly implement the facility's established procedures for a potential missing resident. The facility's conclusion was that the resident who was scheduled for discharge on July 3, 2023, had called her daughter on July 1, 2023, to come and get her. The resident's daughter proceeded to take the resident home without checking with facility nursing staff. The resident was missing from the facility for approximately 5 hours and 30 minutes according to the documentation that was provided at the time of the survey and interviews with staff. Licensed nursing staff were unaware that the resident had left the building until they called the resident's daughter at 2:30 p.m. Staff failed to monitor the resident's whereabouts when staff had not seen the resident in facility after 8:50 a.m. on July 1, 2023. The facility relied on its sign-in/sign-out log to determine when residents leave the nursing unit which was ineffective in preventing Resident 18 from leaving the facility without staff knowledge. Employee 3, RN and Employee 2, LPN failed to timely act on Employee 1's reports that Resident 18's absence from her room and failed to promptly implement procedures to locate a missing resident and to ensure Resident 1's safety. As a result of the failure to adequately supervise a resident's whereabouts and licensed nursing staff's failure to promptly implement procedures for a potential missing resident in response to reports that the resident was not present in the facility, Immediate Jeopardy to the health and safety of residents was identified. The Nursing Home Administrator was notified of the immediate jeopardy and provided the IJ Template on July 6, 2023, at 1:45 p.m. The facility's immediate action plan provided to the survey team at 2:38 PM on July 6, 2023, was as follows: 1. Audit for Profile picture of every resident in-house to be in EMR 2. Audit all residents have had an elopement risk assessment completed 3. Verbal and Written education to all resident on signing out at the nurse's station prior to leaving the floor or the facility. 4. Facility will call all resident family/representative to inform/educate them of the requirement to sign a resident out prior to taking them off the floor or out of the facility for any reason. 5. Education of nursing staff on the timely implementation of procedures for a missing resident. 6. Audit that all residents are present and accounted for. During the onsite visit to the facility on [DATE], verification of the implementation of the facility's removal plan was completed and the Immediate Jeopardy was lifted on July 7, 2023, at 8:30 a.m. 28 Pa Code 201.18(e)(1)(3) Management 28 Pa Code 207.2(a) Administrators Responsibility 28 Pa Code 211.12(a)(c)(d)(3)(5) Nursing Services

Based on review of the Resident Assessment Instrument Manual and clinical records and staff interviews, it was determined that the facility failed to timely submit Minimum Data Set (MDS) assessments to the required electronic system, the CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, for one out of 12 residents reviewed (Resident 7). 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, that assessments must be submitted within 14 days of the MDS Completion Date (Section Z0500B + 14 days). A review of Resident 7's Discharge Return Not Anticipated/End of PPS Part A Stay MDS with an ARD (assessment reference date) of February 2, 2023, indicated that it was completed. This MDS was not submitted/transmitted within 14-days of the MDS Completion Date. The MDS was not submitted until surveyor inquiry during the survey of July 7, 2023. Interview with the RNAC (Registered Nurse Assessment Coordinator) on July 7, 2023, at 9:00 AM, confirmed that Resident 7's completed Discharge Return Not Anticipated/End of PPS Part A Stay MDS was not submitted within 14-days and that the MDS was submitted/transmitted greater than 120 days.

Based on a review of clinical records, select facility policy and reports, and employee job descriptions and staff interview it was determined the facility's administration failed to effectively use its resources to promote resident safety by failing to assure that licensed and professional staff implemented established procedures to maintain resident safety evidenced by one resident identified as missing out of 12 sampled residents (Resident 81) Findings included: A review of an incident/accident report and clinical record revealed that on July 1, 2023, Resident 81 left the facility without staff knowledge. According to the report, clinical record review and the findings of the survey ending July 7, 2023, nursing staff were not aware of her whereabouts for greater than 5 hours and 30 minutes. Nursing staff last observed the resident at approximately 9:15 AM. Staff did not confirm the resident's location until 2:30 PM when they called the resident's second contact and confirmed that the resident left the facility with her daughter and was at her daughter's home in the community. Although a nurse aide, Employee 1, reported to licensed and professional nursing staff (Employees 2 and 3), on two occassions before noon on July 1, 2023, that the resident was not present in her room, these licensed and professional nursing staff members failed to implement the facility's emergency procedures for a missing resident in an attempt to timely locate the resident and determine if the resident was safe. It was later determined that on July 1, 2023, Resident 81 had called her daughter to come and get her and take her home. The resident's daughter came to the facility and picked up the resident, taking her home, without staff knowledge. It was confirmed that on July 1, 2023, the facility failed to implement their procedure for a missing resident and the facility was unaware she had left the facility for an extended period of time and had failed to timely initiate a search for the resident. As a result of these failures, immediate jeopardy to the health and safety and substandard quality of care was identified at the facility on July 6, 2023. A review of the job description for the Administrator of the facility revealed that the administrator is responsible for the planning, organizing, and directing of all operational functions. Overall policies established by the facility's governing body are followed to ensure that objectives of health care, advancement of knowledge, and overall contribution to community welfare are achieved most effectively, economically, and to the satisfaction of patients, employees, and medical staff. The duties of the Nursing Home Administrator are to ensure that operations in the facility are executed in a manner commensurate with the authority conferred by the governing body. Develops mechanisms to implement established policies and ensures compliance with applicable laws and regulations. A review of the job description for the Director of Nursing indicated that under the supervision of the administrator, the Director of Nursing is responsible for the organization and administration for nursing department. The duties of the Director of Nursing include general supervision, guidance, and assistance for a resident in implementing the resident's personal health program to assure the preventive measures, treatments, medications, diet and other health services prescribed are properly carried out and recorded. The deficiency cited under the Code of Federal Regulatory Groups for Long Term Care, Quality of Care (F689) 483.25(d)(1)(2) Accidents, revealed that the NHA and DON failed to fulfill the essential job duties for ensuring the safety of the residents and adherence to regulatory guidelines. Refer F689 28 Pa. Code: 201.12 (a) Responsibility of licensee 28 Pa. Code: 201.18(e)(1) Management 28 Pa. Code:211.12(c) Nursing Services

Based on clinical record and select facility policy review and staff interview, it was determined that the facility repeatedly failed to ensure that the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: A review of facility policy entitled Pain Management Process last reviewed by the facility July 13, 2022, revealed that the license nurse is responsible for the accurate assessment of the resident's pain, initiating the appropriate non-pharmacological and pharmacological pain interventions, evaluating the outcome, and assuring all documentation that is required is met. A review of Resident 8's clinical record revealed a physician order, initially dated July 7, 2022, and discontinued July 19, 2022, for [MEDICATION(S)] 5 mg (medication is used to help relieve moderate to severe pain. [MEDICATION(S)] belongs to a class of drugs known as opioid analgesics with a high risk for addiction and dependence) by mouth every four hours, as needed, for pain. A review of the resident's July 2022, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Of the 25 doses given to the resident from July 7, 2022, to July 19, 2022, all were administered without prior attempts to use non-pharmacological interventions to reduce or alleviate resident's pain. Additionally on July 9, 16, an 18, 2022, the facility staff documented that the resident had a pain level of zero (0) indicating that the resident had no pain, but nursing staff still administered the opioid pain medication. On July 12, 13, 14, 15, 18, and 19, 2022, the facility staff documented that the resident's pain level was not applicable, yet still administered the opioid pain medication. A review of Resident 163's clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It contains an opioid pain reliever ([MEDICATION(S)]) and a non-opioid pain reliever and has a high risk for addiction and dependence) by mouth every four hours, as needed, for moderate pain. A review of the resident's July 2022, MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Of the 10 doses given during the month of July 2022, all were administered without evidence that non-pharmacological interventions were attempted to reduce or alleviate the resident's pain prior to administering the pain medication. On July 28, 2022, the facility staff documented that the resident's pain level was not applicable, but still administered the pain medication to the resident. A review of the resident's August 2022, MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Of the five doses given from August 1, 2022, to August 2, 2022, all were administered without non-pharmacological interventions attempted to alleviate pain prior to administering the pain medication. On August 1, 2022, and August 2, 2022, the facility staff documented that the resident's pain level was not applicable, but yet staff administered pain medication. Interview with the Director of Nursing on August 3, 2022, at 1:35 PM confirmed that the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 28 Pa. Code 211.5(f)(g) Clinical records 28 Pa. Code 211.12(a)(c)(d)(1)(5) Nursing Services

Based on a review of clinical records and select incident reports, and staff interview it was determined that the facility failed to provide necessary staff supervision based on the resident's individual known risk factors, history of falls and displays of unsafe behaviors to prevent a fall resulting in serious injury, a fractured femur, for one of six residents reviewed (Resident CR2). Findings include: A review of clinical record revealed that Resident CR2 was admitted to the facility on [DATE], with diagnoses, which included dementia, heart failure, and history of falls. An Admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated March 7, 2022, indicated that the resident was moderately cognitively impaired and required extensive assistance of one person with bed mobility, transfers, walking, dressing, and toileting. A review of a fall risk assessment dated [DATE], revealed that the resident had a history of falls, had impairments with vision, mobility, and transfers, and was identified at moderate risk for falls. The resident's care plan, initiated February 26, 2022, revealed that the resident was at risk for falls related to impaired mobility, related to use of medications that increase risk of falling. The planned interventions were to a maintain safe, well lit, clutter free environment; keep the resident's call bell and frequently used items within reach, encourage frequent rest periods for fatigue; proper fitting, non-skid footwear at all times; conduct a Fall risk assessment on admission and as needed thereafter; monitor for pain and treat per physician order; physical therapy evaluation and treatment as ordered; review medications that may contribute to increased fall risk; maintain corrective eye wear/ hearing aids in clean, working order and assist resident in wearing as necessary and do not leave the resident alone in the bathroom. The resident's care plan did not identify or address the resident's need for staff supervision or staff monitoring of the resident's status and activities at any planned frequency based on this newly admitted resident's risk for falls and history of falls upon admission. Nursing documentation dated February 25, 2022, at 2:30 PM indicated that the resident was oriented to room and call bell system and educated to not self rise/ ambulate without assistance. There was no indication if this cognitively impaired resident, with a diagnosis of dementia, had understood the education and orientation provided or if the resident was capable of retaining that education to not self rise and ambulate without staff assistance due to the resident's cognitive impairment. Nursing documentation dated February 27, 2022, at 6:58 AM revealed that Resident CR2 made multiple attempts to self rise this shift. Resident re-oriented to call bell system each time with verbal understanding. Resident requires constant reminders throughout the shift. Nursing documentation dated February 28, 2022, at 2:32 PM revealed that according to the resident's family she has a history of being unsafe with ambulation. She did try to stand and walk alone this weekend after toileting needs were met. We will update her care plan for not to be left alone in the bathroom. There was no documented evidence that the facility had updated the resident's care plan to include the need for increased staff supervision and monitoring based on the resident's multiple attempts to self-rise and ambulate without staff assistance, which were known to staff. The facility re-oriented the cognitively impaired resident and recognized that the resident required constant reminders throughout the shift, but failed to plan increased staff monitoring of the resident's activities at any planned frequency as a fall prevention measure. A review of a risk management fall report dated March 4, 2022, at 1:45 PM indicated that the resident tried to get out of bed without staff assistance and the roommate's husband who was visiting in the room alerted staff that Resident CR2 slipped and fell . According to the report, the resident was at her base level of confusion and did not know why she fell . The report indicated that the resident was last seen at 1 PM when she was taken to the bathroom, and the resident had on athletic socks, non-skid. An assessment completed at the time of fall revealed that the resident denied pain and was able to move all extremities with the exception of her right lower extremity (leg). The resident was then sent to the emergency room for an evaluation and treatment. Review of a statement obtained from the visiting husband of the resident's roommate's dated March 4, 2022, indicated that Resident CR2 had just awakened from a nap. He asked her if she had a good nap, and Resident CR2 didn't answer. According to his statement, the next thing he knew, she was getting out of bed, she took a step and started to fall. I got up and grabbed her under her left arm and held her head up, it did not hit the floor. Review of documentation dated March 4, 2022, at 6:05 PM, revealed that Resident CR2 was admitted to the hospital with a diagnosis of a fractured right femur (femur fracture is another term for a broken thighbone. A broken femur is a serious injury that requires immediate medical care. Broken femurs are treated with surgery and physical therapy. It can take months for a broken femur to heal). An interview with the Director of Nursing on April 6, 2022, at approximately 2:30 PM confirmed that the facility failed to provide effective individualized fall prevention measures, including sufficient staff supervision at the level and frequency required, to prevent falls for this newly admitted cognitively impaired resident with a history of falls and known unsafe behaviors of self-rising and unassisted ambulation. 28 Pa Code 211.12(a)(c)(d)(1)(5) Nursing services

Based on a clinical record and select facility policy review and staff interviews, it was determined that the facility failed to demonstrate the clinical necessity of frequent administation of an antianxiety drug, failed to ensure that the resident was free from potential adverse consequences related to the frequency of administration of an antianxiety drug and failed to attempt non-pharmacological measures to reduce anxiety prior to drug administration and for one resident out of 6 sampled residents (Resident CR3). Findings include: Review of a facility policy entitled Medication Monitoring: Psychoactive Drug Monitoring indicated that every effort is made to ensure that residents receiving these medications obtain the maximum benefit with the minimum of untoward effects. The medical necessity is documented in the resident's medical record and in the care planning process. Non-pharmacological interventions such as behavior modification or social services and their effects are documented as part of the care planning process and are utilized by the prescriber in assessing the continued need for psychoactive medication. Initiation and dosing of the psychoactive medications follows recommendations from the medical literature, clinical practice guidelines, and regulations and standards. For antianxiety medications, behavioral monitoring charts or similar mechanism are used to document the resident's need for and response to drug therapy. Review of Resident CR3's clinical record revealed that the resident was admitted to the facility with diagnoses to have included heart failure and [CONDITION(S)] [is when the kidneys permanently fail to work] with need for [CONDITION(S)] treatments [is a blood purifying treatment given when kidney function is not optimum], and anxiety disorder. Review of Resident CR3's physician orders dated January 2, 2022, revealed an order for the antianxiety medication [MEDICATION(S)] 0.5 mg one tablet by mouth as needed (PRN) three times per day for anxiety and agitation for 14 days. Older adults may be more sensitive to the side effects of this drug, especially loss of coordination and drowsiness. Loss of coordination and drowsiness may increase the risk of falling. In the elderly, [MEDICATION(S)] can cause a paradoxical effect. Instead of having a calming effect, it may cause agitation and confusion. Elderly patients taking [MEDICATION(S)] are also at a higher risk of falls. Review of Resident CR3's comprehensive person-centered care plan that was initiated on January 6, 2022, identified that the resident was at risk for falls related to impaired mobility related to the use of medications that increase the risks for falling and at risk due to visual impairments. A Nursing Progress Note dated January 13, 2022, at 3:45 PM, revealed that the resident was agitated since returning from [CONDITION(S)] and was calling out for his mom and wife, and was throwing items and banging on his bed. The PRN [MEDICATION(S)] was administered and was noted to be ineffective. Review of the social services progress note dated January 13, 2022, at 5:59 PM, revealed that the resident was very restless, calling out for his father and that PRN [MEDICATION(S)] was administered. Review of Resident CR3's Medication Administration Record (MAR) dated January 2022, revealed that on January 13, 2022, the resident received PRN [MEDICATION(S)] at 1:37 PM, and at 9:25 PM, and again at 11:38 PM, only 2-hours and 13 minutes after the previous dose. Subsequently, Resident CR3 was incurred a fall on January 14, 2022, at 1:30 AM, which was 2 hours and 8 minutes after receiving the PRN [MEDICATION(S)] dose given at 11:38 PM. Review of the residents Medication Administration Record (MAR) for January 5, 2022, at 9:40 PM, revealed that PRN (as needed) [MEDICATION(S)] was administered per physician's orders due to anxiety. Review of Resident CR3's clinical record Progress Notes dated January 5, 2022, at 11:26 PM, revealed that the resident had noted self-rising, was agitated, unsteady on his feet, and more confused. Bed and chair alarms were put in place. Subsequently, progress notes dated January 6, 2022, at 2:30 AM, the resident had a fallen and was sent to the emergency room due to a change in condition. Upon return the resident's every 2-hour toileting was implemented. A Nursing Progress Note dated January 13, 2022, at 3:45 PM, revealed that the resident was agitated since returning from [CONDITION(S)], and was calling out for his mom and wife, and was throwing items and banging on his bed. The PRN [MEDICATION(S)] was administered and was noted to be ineffective. Review of the social services progress note dated January 13, 2022, at 5:59 PM, revealed that the resident was very restless, calling out for his father and that PRN [MEDICATION(S)] was administered. Review of Resident CR3's Medication Administration Record (MAR) dated January 2022, revealed that on January 13, 2022, staff administered PRN [MEDICATION(S)] at 1:37 PM, and at 9:25 PM, and again at 11:38 PM, only two hours and 13 minutes after the previous dose. Resident CR3 later incurred a fall on January 14, 2022, at 1:30 AM, 2 hours and 8 minutes after staff had administered a PRN [MEDICATION(S)] dose given at 11:38 PM. A nurse aide responded to the resident's bed alarm sounding and found Resident CR3 lying on the floor on his left side between the resident's bed and the wall. The resident had removed his oxygen prior to fall. Resident CR3 stated that he hit his head and the facility implemented every 15-minute checks. Nursing noted on January 14, 2022, at 8:43 PM, revealed that the resident was restless and had fallen from his bed at 9:12 PM from his bed and acquired small open areas on his left arm. Fall mats were put in place. The physician's order for the PRN [MEDICATION(S)] TID failed to specify the duration (time) between doses for the medication to be administered to deter potential side effects of the [MEDICATION(S)]. The facility also failed to provide documented evidence that non-pharmacological interventions had been attempted prior to administration of the PRN anxiety medication. The facility failed to clinically justify the administration of Resident CR3's [MEDICATION(S)] given on January 13, 2022, at 11:38 PM, which was only 2 hours and 13 minutes after the previous PRN dose given at 9:25 PM, after which the resident incurred a fall at 1:30 AM. Interview with the Director of Nursing (DON) on April 6, 2022, at 2:30 PM, confirmed that the facility failed to ensure the PRN physician's orders for an antianxiety medication included a specified duration between doses, and verified there was no documented evidence that non-pharmacological interventions were attempted to reduce the resident's anxiety prior to administration of a PRN psychoactive medication. 28 Pa Code 211.2(a) Physician services 28 Pa Code 211.5 (f)(h) Clinical records 28 Pa Code 211.9(a)(l)(k) Pharmacy services 28 Pa Code 211.12(a)(c)(d)(1)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to provide a sanitary environment in the food and nutrition services department. Findings include: During an initial tour of the food and nutrition services department accompanied by the director of food and nutrition services on September 8, 2021, at 8:30 AM a thick layer of dust was observed on the fins of the air conditioning unit located in the food prep area of the department. Interview with the food and nutrition services department at this time confirmed the observation. 28 Pa. Code: 207.2 (a) Administrator's responsibility.

Based on review of clinical records and transfer notices and staff interview it was determined the facility failed to provide a detailed written notice of a facility-initiated transfer to the hospital to the resident and the resident's representative for one out of two residents reviewed for transfers/hospitalization s (Resident 6). Findings include: A review of the clinical record of Resident 6 revealed that the resident was transferred to the hospital on May 27, 2021 and readmitted to the facility on [DATE]. Further review of the clinical record revealed no documented evidence that a detailed written notice of Resident 6's facility-initiated transfer to the hospital was provided to the resident and the resident's representative. Interview with the administrator on September 10, 2021 at approximately 9:00 AM confirmed the written notice of transfer, that included the reason for transfer in an understandable language and contained the necessary contact and appeal information required, had not been provided to the resident and the resident's representative. 28 Pa. Code 201.29 (f)(g)(j) Resident Rights 28 Pa. Code 201.14(a) Responsibility of Licensee

Based on observation, staff interview and review of manufacturer's directions for use, it was determined that the facility failed to maintain acceptable practices for the storage of food to prevent the potential for microbial growth in foods and conditions which increased the risk for food borne illness. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). During the initial tour of the food and nutrition services department, with the Manager of Food Services, on March 3, 2020, at approximately 9:45 a.m., observations of the kitchen area on March 3, 2020, at approximately 9:58 a.m., revealed 15 four ounce (oz.) vanilla health shakes (nutritional supplement) dated February 2, 2020, three four oz. vanilla health shakes dated dated February 6, 2020 and 17 four oz. vanilla health shakes. The Manager of Food Services stated that the noted dates on health shakes indicated the dates health shakes were pulled from freezer and these supplements have a shelf life of 30 days once thawed. A review of the manufacturer's directions for use, revealed that the shelf life of the nutritional health shakes, is 14 days after thawing. Interview with the Manager of Food Services on March 3, 2020, at 10:17 a.m., confirmed that the food and nutrition services guidelines were to be followed for food storage. 28 Pa Code 207.2 (a) Administrator's responsibility. 28 Pa Code 211.6 (c)(d) Dietary services.

Based on clinical record and select policy review and staff and resident interview, it was determined the facility failed to include, in the resident's baseline plan of care, minimum standards of care required for one resident reviewed with a brain stimulator implant out of 12 residents reviewed (Resident 144). Findings include: A review of the clinical record of Resident 144 revealed admission to the facility on [DATE], with a [DIAGNOSES REDACTED]. The resident had an implanted battery operated medical device in her left upper chest area that is connected with the brain stimulator. The device requires observation to ensure the battery is charged. The brain stimulator device requires monitoring for severe or prolonged headaches, increased confusion, difficulty concentrating, sudden onset of dizziness, [MEDICAL CONDITION], symptoms of stroke, speech disturbance and double vision. A review of the resident's initial (baseline) plan of care indicated that the resident had neurological deficits related to [MEDICAL CONDITION], but failed to address the brain stimulator and the potential side effects related to the brain stimulator. During an interview with the Director of Nursing on March 6, 2020, she that the implanted device to control the resident's symptoms of [MEDICAL CONDITION] was not included on the resident's baseline care plan. 483.21 (a)(1) Baseline Care Plans Previously cited 2/20/19 28 Pa. Code 211.11(c)(d) Resident care plan Previously cited 2/20/19, 5/14/19

Based on review of narcotic shift count records and staff interview, it was determined that the facility failed to implement procedures to promote accurate narcotic medication records on one of seven medication carts. Finding include: A review of the facility's policy entitled Administration of Medication Schedule II-V Control Drugs reviewed by the facility (MONTH) 1, (YEAR), revealed that at each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and documented on the aforementioned form. A review of the Narcotic Record form for the East Hall and West Hall medication carts on (MONTH) 21, 2019, at approximately 8:11 a.m., revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during multiple shifts on the following dates to verify counts of controlled drugs in the respective medication carts: (MONTH) 4, 5, 8, 10, 11, 12, and 18, 2019. Interview with the registered nurse consultant on (MONTH) 22, 2019, at approximately 9:07 a.m. confirmed that there were no nursing staff signatures on the dates noted above to demonstrate consistent implementation of facility procedures for promoting accurate drug records. 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services. Previously cited 3/9/18 28 Pa Code 211.9(a)(1)(k)Pharmacy services.

Based on a tour of the food and nutrition services department, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for microbial growth in food, which increased the risk of food-borne illness. Findings include: During the initial tour of the food and nutrition services department on (MONTH) 20, 2019, at approximately 8:19 a.m. accompanied by the certified dietary manager (CDM), the following sanitation issues, with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified: A dust build-up was observed in the vents on the wall-mounted air conditioner. An accumulation of dust was observed on top of the two convection ovens, the steamer, the coffee machine and on the ledge above the dish machine. The lid on the rice container (bulk) located near the deep fat fryer was observed covered with grease and dust. The inside of the tray cart was observed to be soiled with dust and dried food. Food debris was observe on the gaskets on the doors of the reach-in refrigerator and freezer; one gasket was ripped. A heavy grease and dust build-up was observed on the ceiling vent located in the dish machine room. Interview with the CDM at this time, confirmed the above observed food safety and sanitation concerns. 28 Pa. Code 211.6(c)(d) Dietary services. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on observation, staff interview and review of facility policy, it was determined that the facility failed to implement procedures to effectively clean and disinfect glucose meters (a medical device for determining the approximate concentration of glucose {sugar} in the blood) in a manner to prevent the potential spread of infection. Findings include: Review of the facility policy entitled Nova Stat Strip Glucose Monitor last reviewed by the facility (MONTH) 1, (YEAR), revealed that the aforementioned glucose monitor must be cleaned between each resident use with a bleach germicidal (an antiseptic wipe that destroys harmful microorganisms) wipe. Procedures include wiping the external surface of the meter using a fresh germicidal wipe. The surface of the meter should be thoroughly wiped at a minimum of three times both horizontally and vertically. Further review of the policy, indicated that staff should ensure the meter surface stays wet for one minute and then allowed to air dry for an additional minute. This type of meter was the meter the facility utilized for each resident requiring blood glucose testing. Observation of a medication administration pass on (MONTH) 21, 2019, at approximately 7:41 a.m. revealed that Employee 1 (LPN) obtained Resident 179's blood using a glucose meter (Nova Stat Strip Glucose Monitor) to determine the resident's blood glucose level. After documenting the amount of glucose on the Medication Administration Record, [REDACTED]. Interview with Employee 1 at approximately 8:15 a.m. confirmed that she used alcohol wipes, not germicidal wipes. During an interview on (MONTH) 22, 2019, at approximately 9:19 a.m. the registered nurse consultant confirmed that alcohol wipes are not effective against [MEDICAL CONDITION] bloodborne pathogens and that staff failed to follow facility policy regarding the use of germicidal wipes. 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services. Previously cited 3/9/18 28 Pa. Code 211.10 (a)(d) Resident care policies.

Based on clinical record and select policy review and staff and resident interview, it was determined the facility failed to include, in the resident's baseline plan of care, minimum standards of care required for one resident out of one resident on transmission based precautions (Resident 172). Findings include: A review of the clinical record of Resident 172 revealed admission to the facility on (MONTH) 16, 2019, for aftercare following joint replacement. The resident was admitted to the facility on isolation precautions for Multi Drug Resistant Organisms (MDRO's)[MEDICAL CONDITION] of the nares. A review of the resident's initial (baseline) plan of care failed to indicate that the resident was on isolation (contact) precautions. The facility policy entitled Infection Control Policy and Procedure dated (MONTH) 2014 indicated the application of contact precautions for patients infected or colonized with MDRO's. According to the policy, all departments who may come in contact with the resident will be notified, nursing will place a please see nurse magnet on the door frame. Patients on contact precautions according to this policy require either a private room or cohorting, dedicated disposable equipment, healthcare workers should wear gloves, encourage patients to wash hands frequently and visitors should clean hands when they enter and leave the room. Interview with the Director of Nursing on (MONTH) 22, 2019, confirmed that the facility failed to indicate on the baseline care plan that the resident was on contact precautions. 28 Pa. Code 211.11(c)(d) Resident care plan Previously cited 3/9/18