Every finding on record at Berks Heim Nursing & Rehabilitation

Based on clinical record review and staff interview, it was determined that the facility failed to document the rationale for the continued use of as needed (PRN) anti-anxiety medications for one of five sampled residents who were on psychotropic medications. (Resident 83)Findings include:Clinical record review revealed that Resident 83 had diagnoses that included dementia with behavioral disturbance and anxiety. The Minimum Data Set assessment dated [DATE], indicated that the resident had been administered an anti-anxiety medication. A review of the care plan revealed that the resident used an anti-anxiety medication related to an anxiety disorder. There was an intervention for staff to administer medications as ordered. On June 24, 2025, a physician ordered for staff to administer an anti-anxiety medication, Lorazepam gel, for anxiety every eight hours as needed. Review of the Medication Administration Records revealed that the Lorazepam gel had been administered five times in July 2025, five times in August 2025, and nine times in September 2025. There was no documentation in the clinical record from the physician for the rationale to extend the PRN Lorazepam gel beyond 14 days from the original order on June 24, 2025. In an interview on October 10, 2025, the Director of Nursing confirmed that there was no stop date or rationale in the orders to extend the PRN Lorazepam medication. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to store foods in a sanitary manner in the dietary department to prevent the potential for foodborne illness. Findings include: Review of the facility policy entitled, Storing: Food and Equipment, last reviewed March 14, 2024, revealed that food was to be stored in a manner that ensured quality and freshness and safeguarded against foodborne illness. The policy indicated that staff was to ensure all food items were labeled. The label was to include product name, use by date, and date the product was prepared or opened. If applicable, the label was to include the date frozen or thawed. Containers were to be covered, labeled, and dated. All food bins were to be covered. Observation during the initial tour of the dietary department on September 17, 2024, at 9:45 a.m., revealed the following: Warming Cabinet (large, tall warming oven) #1 had five containers of prepared food items that were not labeled or dated. The Dietary manager had to uncover the containers to identify the food that was in them and she was not aware of when the containers had been placed in the warming cabinet. Warming Cabinet #2 had a container of pureed chicken that was not dated. There were also several mugs of fortified food that were not labeled or dated. In addition, there was a container of ground chicken that was not dated. On the other side of the warming cabinets in the dietary department, there were air curtain refrigerators. The Dietary Manager stated that staff was to place prepared food on trays inside of the air curtain refrigerators. The staff was to cover, label, and date the food items on these trays. Air curtain refrigerator #1 had five trays of multiple cups of regular prepared peppered cabbage. None of the cups were covered or dated. There were two trays of several cups of pureed peppered cabbage that were not covered or dated. There was a tray with several bowls of tossed salad that were not labeled or dated. Air curtain refrigerator #2 had nine trays of several cups of desserts that were not labeled, dated, or covered. In another large refrigerator in the dietary department, there were seven trays of several dishes of desserts that were not covered, labeled, or dated. In an interview on September 17, 2024, at 10:00 a.m., the Dietary Manager stated that all prepared foods were to be covered, labeled, and dated as per facility policy and standards of practice to prevent foodborne illness. 201.14(a) Responsibility of licensee.

Based on clinical record review and staff interview, it was determined that the facility failed to document the rationale for the continued use of as needed (PRN) anti-anxiety medications for two of five sampled residents who were on psychotropic medications. (Residents 40, 51) Findings include: Clinical record review revealed that Resident 40 had diagnoses that included dementia with behavioral disturbance and anxiety. On February 19, 2023, a physician ordered for staff to apply an anti-anxiety gel (Ativan gel) PRN for anxiety and the order was still current for the PRN medication. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had memory impairment and had been administered an anti-anxiety medication in the last seven days of the assessment period. Review of the Medication Administration Records (MAR) revealed that staff had administered the PRN anti-anxiety medication 13 times in June, nine times in July, seven times in August, and nine times in September 2024. There was no documentation in the clinical record from the physician for the rationale to extend the PRN Ativan gel beyond 14 days from the original order on February 19, 2023. Clinical record review revealed that Resident 51 had diagnoses that included Alzheimer's disease and anxiety disorders. On March 22, 2024, a physician ordered for staff to administer an anti-anxiety medication (Ativan) every four hours PRN for anxiety. The MDS assessment dated [DATE], indicated that the resident had memory impairment and had been administered an anti-anxiety medication in the last seven days. Review of the MAR revealed that staff had administered the PRN anti-anxiety medication two times in June, one time in July, eight times in August, and three times in September 2024. There was no documentation in the clinical record from the physician for the rationale to extend the PRN Ativan beyond 14 days from the original order on March 22, 2024. In addition, review of pharmacy recommendations for Resident 51 revealed that on May 27, 2024, and again on June 17, 2024, the pharmacist recommended to include the duration of time for the Ativan PRN order. The physician failed to acknowledge both recommendations and failed to act upon the recommendations in a timely manner related to the use of the PRN Ativan. In an interview on September 19, 2024, the Director of Nursing confirmed that there was no stop date or rationale in the orders to continue to extend the PRN Ativan for either resident. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and review of facility documentation, it was determined that the facility failed to ensure that assessed safety interventions were in place to prevent falls for one of seven sampled residents who were at risk for falls. (Resident 152) Findings include: Clinical record review revealed that Resident 152 had diagnoses that included anxiety, a history of falling, abnormal gait and mobility, a lack of coordination, and unsteadiness on her feet. The Minimum Data Set assessments dated June 6, 2024, and August 2, 2024, indicated that the resident had some memory impairment, used a walker, and had experienced two or more falls during both of the assessment periods. Review of the care plan revealed that the resident was at risk for falls due to being unaware of her safety needs. There was an intervention from March 1, 2024, for staff to ensure that the resident wore appropriate footwear when ambulating. There was another intervention from June 18, 2024, for staff to encourage the resident to wear non-skid socks at night. Review of nursing documentation revealed that the resident had fallen six times on the evening shift from July through September 2024. Review of facility documentation dated September 5, 2024, revealed that at 9:34 p.m., the resident had been walking on the nursing unit with her wheeled walker. The resident fell backwards and hit her head on the floor. The resident had been wearing regular socks. The interdisciplinary review of the fall revealed that the facility had failed to ensure that the resident had appropriate, non-skid footwear on when she had been walking on the nursing unit. CFR 483,25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 10/20/23 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) assessment for two of 36 sampled residents. (Residents 60, 65) Findings include: Clinical record review revealed that section P of the MDS assessment dated [DATE], indicated that Resident 60 used a trunk restraint while in chair or out of bed daily during the seven-day review period. Review of Resident 60's clinical record revealed that Resident 60 did not have a physician's order for and did not use a trunk restraint while in chair or out of bed during the seven-day review period, as inaccurately identified on the MDS assessment. Clinical record review revealed that Resident 65 had diagnoses that included end stage renal disease. Review of Resident 65's care plan revealed she required hemodialysis. On November 7, 2022, the physician ordered for the resident to receive dialysis on Mondays, Wednesdays, and Fridays. Review of the MDS assessment, dated August 29, 2024, did not indicate that Resident 65 received dialysis.

Based on observation and resident interview, it was determined that the facility failed to ensure that meals were served in a manner that maintained each resident's dignity on one of six nursing units. ([NAME] Commons) Findings include: Observations of the lunch meal on [NAME] Commons nursing unit on Ocotber 18, 2023, between 12:18 p.m. and 1:05 p.m., revealed Residents 120 and 247 seated at a table, taking utensils and food off each other's meal trays. Resident 120 then proceeded to eat her meal using a folded piece of paper as a utensil. During the same observation period, Resident 299 was seated at the table next to Residents 120 and 247. Resident 299 was observed making comments like I'm hungry, where is the food, it's ridiculous to wait, and why are they eating? Resident 299 was not served her lunch tray until 1:05 p.m. Observation of the lunch meal on [NAME] Commons nursing unit on October 19, 2023, between 12:41 p.m. and 1:04 p.m., revealed residents 142, 282, and 296 seated at a table. The residents had been served and were eating their lunch meals. Residents 185 and 246 were seated in chairs, next to the table while residents 142, 282, and 296 ate their meals. Resident 246 was not served a lunch tray until 1:03 p.m. During the same observation period, Residents 100, 239, 134, and 82 were seated together at a table. Residents 100, 134, and 239 were served a lunch tray and were eating their meals. Resident 82 was not served a lunch tray until 1:04 p.m. 28 Pa. Code 201.29(a) Resident rights.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that safety interventions for falls were in place for two of 37 sampled residents. (Residents 162, 297) Findings include: Clinical record review revealed that Resident 162 had diagnoses that included dementia, anxiety, unsteadiness on feet, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had cognitive impairment and required extensive assistance from staff with transferring, personal hygiene, and dressing. Review of the care plan revealed that staff was to use bilateral (both sides) elevating leg rests for transport in the wheelchair. On October 18, 2023, at 12:20 p.m., and October 19, 2023, at 10:47 a.m. and 1:15 p.m., Resident 162 was observed in her wheelchair being transported by staff without bilateral elevating leg rests in the hallway. In an interview on October 20, 2023 at 9:24 a.m., the Director of Nursing confirmed that staff should have used bilateral elevating leg rests when transporting Resident 162 in her wheelchair. Clinical record review revealed that Resident 297 had diagnoses that included dementia, anxiety, osteoarthritis, and unsteadiness on feet. Review of the MDS assessment dated [DATE], revealed that the resident had cognitive impairment. Review of the care plan revealed that staff were to ensure that the resident had his walker with him at all times while ambulating. Review of a facility incident report dated October 17, 2023, revealed that Resident 297 was standing in the hallway holding the rail on the wall and needed to be lowered to the floor by staff. The intervention was for staff to encourage the use of a walker while the resident was ambulating and to offer rest periods. On multiple occasions on October 18, 2023, between 12:14 p.m. and 12:56 p.m., Resident 297 was observed ambulating in the common area without his walker. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and resident interview, it was determined that the facility failed to accomodate resident needs by providing access to the call bell system and personal items for one of 37 sampled residents. (Resident 195) Findings include: Clinical record review revealed that Resident 195 had diagnoses that included Parkinson's disease. According to the Minimum Data Set assessment, dated October 5, 2023, the resident had no cognitive impairment, could communicate care needs, had impaired vision, and was dependent on staff for care. Review of the care plan revealed that the resident was at risk for falls and that staff was to keep her call bell and other objects within reach. On October 17, 2023, at 11:09 a.m., the resident was observed in her chair near the foot of the bed. The call bell was at the head of the bed. The resident stated at that time that she could not reach it. On October 18, 2023, at 9:45 a.m., the resident was observed in her chair near the foot of the bed. The television remote control was on the floor. The resident's cell phone was on the overbed table and out of reach. Her call light was under a pillow that was propping her arm and the resident stated she could not reach these items. On October 19, 2023, at 11:02 a.m., the resident was observed seated in her chair near the foot of the bed. The call bell was on the overbed table at the foot of the bed. The resident stated that she could not reach it. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 37 sampled residents. (Resident 137) Findings include: Clinical record review revealed that Resident 137 had diagnoses that included hypertension (high blood pressure). On September 6, 2023, the physician ordered staff to administer a blood pressure medication (metoprolol tartrate) twice a day. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 105 millimeters of mercury (mmHg). Review of Resident 137's medication administration records revealed that staff administered the medication when the resident's SBP was less than 105 mm/Hg one time in September and four times in October of 2023. In an interview on October 20, 2023, at 12:35 p.m., the Assistant Director of Nursing (ADON1) confirmed that the medications were administered outside of established parameters for Resident 137. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, facility documentation review, observation, and staff interview, it was determined that the facility failed to provide adequate supervision and interventions to prevent accidents related to falls for two of 36 residents (Residents 94 and 187) which resulted in actual harm of a bone fracture for one resident. (Resident 187) Findings include: Clinical record review revealed that Resident 187 had diagnoses that included dementia (disease that causes progressive cognitive impairment that includes memory loss and personality changes), abnormalities of gait and mobility, unsteadiness on feet, muscle weakness (generalized), and repeated falls. The Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs) dated June 2, 2022, indicated that the resident had memory problems, was severely impaired for daily decision making, used a walker, required staff assistance for walking, and had a history of falling. The care plan identified that Resident 187 was at risk for falls and interventions added on August 6, 2021, included that the resident needed a safe environment and to maintain a clear pathway, free of obstacles. Review of facility incident report documentation revealed that Resident 187 had an unwitnessed fall in the hallway on May 17, 2022, at 7:45 p.m., did not have her walker close by, and sustained a hematoma (a swollen collection of blood in the tissues) to the back of the head and a bruise to the right knee. Interventions to prevent falls included that staff was to ensure the walker was within reach and to continue therapy. According to the physical therapy discharge summary dated June 7, 2022, the therapist recommended that the resident receive assistance of one staff with rolling (wheeled) walker for all transfers (moving from one surface to another) and ambulation (walking). Review of behavioral documentation dated June 6, 2022, revealed that the resident sometimes forgot to use the walker. Nursing documentation dated June 29, 2022, identified an incident where the Resident 187 screamed and staff found the resident on a floor mat in another resident's room. At that time the resident complained of right shoulder and arm pain. Review of the facility incident report revealed that the resident fell at 2:45 p.m., and it was determined that Resident 187 had probably tripped over mats that remained on the floor after the other resident was out of bed and that the walker had been left in the hallway. A witness statement indicated that the resident had also been observed walking without the walker earlier the same day. A radiology report dated June 29, 2022, indicated that the resident sustained a fracture of the proximal head of the right humerus (top part of the long bone in the arm that runs from the shoulder to the elbow). Clinical record review revealed that Resident 94 had diagnoses that included dementia, unsteadiness on feet, and repeated falls. The MDS assessment dated [DATE], indicated that the resident was cognitively impaired with memory problems and required staff assistance for transfers and ambulation. The care plan identified that the resident was at moderate risk for falls and for staff to ensure that the resident was wearing proper footwear when walking or moving about in the wheelchair. Review of facility incident reports revealed that the resident fell on [DATE], and October 3, 2022, while wearing Crocs footwear (a brand of foam clog with an adjustable heel strap). Documentation on the reports indicated that the probable cause of each fall was that the resident was wearing this type of shoe which did not provide adequate support, causing her to trip. Fall risk evaluations completed for Resident 94 on September 20 and October 3, 2022, identified that the resident was at high risk for falls. During an interview on November 4, 2022, at 1:40 p.m., the Nursing Home Administrator confirmed that proper footwear had been obtained for the resident on October 6, 2022. Observation revealed that Resident 94 was wearing Crocs foam clog footwear on November 1, 2022, at 10:12 a.m., and November 2, 2022, at 9:40 a.m., with the alternate footwear placed under the resident's bed. CFR: 483.25(d) Accidents Previously cited 12/03/2021. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(a)(b)(1)(d) Management. 28 Pa. Code 211.12(c)(d)(1)(2)(5) Nursing Services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to monitor and assess nutrition status for three of seven sampled residents at nutritional risk. (Residents 74, 259, 266) Findings include: Review of facility policy entitled, Weighing of Residents and Point Click Care Documentation, dated January 12, 2022, revealed that if a resident exhibited a weight change of five or more pounds (lbs.) from their previous weight, and the resident was over 100 lbs., the resident should be re-weighed within 24 hours and the re-weigh should be recorded. A resident may be placed on weekly weights and nursing, medical doctor, and/or dietary designee will monitor the weekly weights. Resident weight records would be monitored at a minimum, on a weekly basis by the Registered Dietitian and/or designee. Clinical record review revealed that resident 74 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On September 1, 2022, the resident weighed 200.0 lbs., on October 13, 2022, the resident weighed 191.3 lbs., a weight loss of 8.7 lbs. from the previous weight. There was no evidence that a re-weigh was obtained within 24 hours of the weight loss that was identified on October 13, 2022, per the facility policy. Clinical record review revealed that Resident 259 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On August 29, 2022, the resident weighed 180.7 lbs., on September 8, 2022, the resident weighed 172.0 lbs., an 8.7 lb. weight loss from the previous weight. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence that the resident was weighed during the weeks of September 18, 2022, or October 2, 2022, per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Clinical record review revealed that Resident 266 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On July 5, 2022, the resident weighed 130.8 lbs., and on August 5, 2022, the resident weighed 117.6 lbs., a 13.2 lb. loss from the previous weight. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence that the resident was weighed during the weeks of August 14 or 21, 2022, per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on November 4, 2022, at 3:20 p.m., the Nursing Home Administrator confirmed there was no evidence that the weights were obtained weekly per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] CFR 483.25(g)(1) Maintain acceptable parameters of nutritional status Previously cited 12/03/21 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on clinical record review, and resident and staff interview, it was determined that the facility failed include a resident in care plan developement and review, and discharge care planning for two of 36 sampled residents. (Residents 159, 161) Findings include: Clinical record review revealed that Resident 159 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was not cognitively impaired. On August 18, 2022, the facility held a care plan meeting to review Resident 159's plan of care. There was no evidence that Resident 159 was invited to, or attended, the care plan meeting. In an interview on November 4, 2022, at 2:27 p.m., the Nursing Home Administrator confirmed that Resident 159 was not invited to, and did not participate in, the care plan meeting. Clinical record review revealed that Resident 161 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on November 1, 2022, at 1:00 p.m., Resident 161 indicated that she is independent with most activities of daily living and that she would like to be discharged from the facility. Resident 161 stated that she had expressed her desire to be discharged to staff and felt that they were not listening to her. Review of the behavioral health services note on August 26, 2022, revealed that Resident 161 stated she was upset being at the facility, she was doing very well on her medications, and continually talked about wanting to leave the facility. The psychiatrist recommended a home safety evaluation and an evaluation by a psychologist regarding discharge. On September 27, 2022, the social worker meet with Resident 161 and noted that she expressed that she wanted to be discharged to her own place and live independently. There was no documented evidence that a home safety evaluation or psychological evaluation regarding the resident's desire to be discharged were ever offered to the resident or completed. In an interview on November 4, 2022, at 10:30 a.m., the Nursing Home Administrator confirmed that discharge options for Resident 161 had not been discussed with the resident. 28 Pa. Code 211.11(e) Resident care plan.

Based on clinical record review, observation and resident interview, it was determined that the facility failed to ensure that a homelike environment was maintained for one of 36 sampled residents (Resident 168). Findings include: Clinical record review revealed that Resident 168 had diagnosis that included diabetes and overactive bladder. Review of the Minimum Data Set assessment, dated September 28, 2022, revealed Resident 168 had no cognitive impairment and required extensive assistance from staff with activities of daily living. On November 1, 2022, from 10:48 a.m. until 12:52 p.m., and November 2, 2022, at 9:38 a.m., Resident 168's bed was observed without sheets. In an interview on November 1, 2022, at 10:48 a.m., Resident 168 stated she wished that staff would make her bed. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on clinical record review, it was determined that the facility failed to complete a comprehensive assessment for one of 36 sampled residents. (Resident 122) Findings include: Clinical record review revealed that Resident 122 was admitted [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set assessment dated [DATE], revealed that Section F, Preferences for Customary Routine and Activities indicated that an interview for daily preferences and activities should not be conducted due to the resident was rarely/never understood and family/significant other was not available. Review of the clinical record revealed that the resident's spouse was the responsible party and that he visited the facility during the assessment period. There was no documentation to support that an attempt was made to interview the resident's responsible party for completion of Section F of the MDS assessment.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of 36 sampled residents. (Resident 257) Findings include: Clinical record review revealed that Resident 257 had a Minimum Data Set (MDS) assessment that was completed on October 12, 2022. According to the assessment, the resident had pressure ulcers. According to the Care Area Assessment summary from that assessment, the facility identified that pressure ulcers were a problem for the resident, and should have been included on the resident's comprehensive plan of care. Review of the care plan revealed that the facility did not develop any interventions to address the resident's pressure ulcers. In an interview on November 4, 2022, at 3:13 p.m., the Nursing Home Administrator confirmed that pressure ulcer interventions were not included in Resident 257's care plan. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, incident report review and staff interview, it was determined that the facility failed to revise a care plan to meet the current needs of three of 36 sampled residents. (Residents 64, 94, 205) Findings include: Clinical record review revealed that Resident 64 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 64's care plan revealed that the resident had behaviors of verbally threatening staff, delusions, and wandering. Review of incident reports revealed that on [DATE], the resident had an episode of delusions and became physically aggressive towards staff and the environment. The care plan failed to address the physical behaviors or include facility developed interventions for for the physical behaviors. In an interview on [DATE], at 3:18 p.m., the Director of Nursing confirmed that the care plan did not address the new physical behaviors. Clinical record review revealed that Resident 94 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS assessment, dated [DATE], indicated that the resident had verbal and other behavioral symptoms. In addition, nursing documentation [DATE], through [DATE], revealed the resident had multiple episodes of mood/behavioral symptoms, including crying, exit-seeking, and looking for her husband who had expired. Review of the resident's care plan revealed that there were no psychosocial interventions to address the resident's mood and behavioral symptoms. Clinical record review revealed that Resident 205 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 205's care plan revealed that the resident was at risk of falls. Review of incident reports revealed that on [DATE], the resident leaned forward to reach and fell from the wheelchair. The incident report further revealed that the resident would be provided a reacher and that the care plan would be updated with the intervention. The care plan failed to include the facility developed intervention for a reacher. In an interview on [DATE], at 1:49 p.m., the Administrator confirmed that the care plan did not include the intervention for a reacher. 28 Pa. Code 211.11(d) Resident care plan.

Based on clinical record review, and staff and resident interview, it was determined that the facility failed to provide services to improve activities of daily living including communication for two of 36 sampled residents. (Residents 34, 159) Findings include: Clinical record review revealed that Resident 34 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The intervention was for use of alternate communication tools as needed, such as a communication board or writing pad. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 34 had moderate difficulty with hearing, and unclear speech. On November 3, 2022, at 1:31 p.m., a dry erase writing pad was observed on the wall on Resident 34's room. The marker attached to the dry erase writing pad was not functioning and unable to be used for communication. In an interview on November 4, 2022, at 11:04 a.m., the Nursing Home Administrator confirmed that the dry erase writing pad and marker are communication tools and should be available to use as required by the resident. Clinical record review revealed that Resident 159 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan revealed that Resident 159 had a communication problem related to a language barrier and communicated in only Spanish. The interventions were to utilize Spanish speaking staff and ensure the availability of adaptive communication equipment. Review of the MDS assessment dated [DATE], revealed that Resident 159's vision was highly impaired. In an interview translated by Nurse Aide 1 (NA1) on November 2, 2022, at 10:44 a.m., Resident 159 stated a preference to communicate in Spanish. In an interview on November 1, 2022, at 1:35 p.m., Licensed Practical Nurse 1 (LPN 1), stated that there was no adaptive communication device available for use with Resident 159. In an interview on November 2, 2022, at 10:07 a.m., Registered Nurse 1 (RN 1), stated that there was no adaptive communication device available for use with Resident 159. There was no evidence that staff were aware of the availability of adaptive communciation devices for communicating with Resident 159 as needed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide an activity program that met the needs and interests of residents in accordance with care planned interventions for two of nine sampled residents on the [NAME] Commons (dementia) unit. (Residents 122, 240) Findings include: Clinical record review revealed that Resident 122 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs), dated August 11, 2022, indicated that the resident required extensive assistance from staff to move about the unit. Review of the care plan revealed that the resident was dependent on staff to attend activities and favorite recreational activities included spending time with the dog, cooking, and watching television and that the resident was to be invited to scheduled activities and provided with one to one visits if unable to attend. The social worker's documentation, dated March 29, 2022, indicated that the resident would like to meet the chaplain and attend chapel services. Review of the October 2022 activities calendar for [NAME] Commons revealed that bible study was offered twice per week. There was a lack of documentation to support that the resident was invited to any religious activities/services in October. In addition, there was documentation of her involvement in four scheduled activities in October; one of those was Resident Council (which would not have been a meaningful activity based on the resident's impaired cognition.) Resident 122 was observed on all days of the survey with no involvement in any scheduled activities. Clinical record review revealed that Resident 240 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment, dated July 15, 2022, indicated that the resident was dependent on staff to move about the unit and that listening to preferred music was very important. Review of the resident's care plan revealed that the resident was dependent on staff for activities, cognitive stimulation, and social interaction. Review of an activities assessment dated [DATE], and the care plan revealed that the resident enjoyed listening to music. Observation of Resident 240 on all days of the survey revealed a lack of participation in scheduled activities. On November 3, 2022, from 10:49 a.m. through 11:02 a.m., Resident 240 was observed in a wheelchair in the corridor across from the nurses' desk on the [NAME] Commons unit. The resident was seated alone and looking up at the ceiling. During that time, a musical group activity was taking place in the furthest section of the high side of the unit. There was no evidence that the resident was invited to attend the activity. Observation on the [NAME] Commons nursing unit on November 2, 2022, revealed that activities scheduled for 9:30 a.m. and 2:30 p.m. did not take place and there were no activities on the unit. In an interview on November 3, 2022, at 11:30 a.m., Activities Staff (AS 1) assigned to the [NAME] Commons unit confirmed that the activities did not take place due to staff being assigned to other duties/areas. 28 Pa. Code 201.29(j) Resident rights.

Based on facility policy review, clinical record review, staff interview, and observation, it was determined that the facility failed to ensure pressure ulcer treatments were done in accordance with facility policy for one of 36 sampled residents. (Resident 20) Findings include: Review of the facility policy entitled Skill: Dressing Change - Clean Technique, last reviewed January 12, 2022, revealed that during the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Clinical record review revelaed that on October 25, 2022, the physician ordered that staff clean the pressure ulcer on Resident 20's lower back with normal saline and apply [MEDICATION(S)] (antimicrobial wound dressing) and a dry dressing. On November 2, 2022, at 1:28 p.m., licensed practical nurse (LPN) 2 was observed providing the prescribed treatment to Resident 20's lower back. LPN 2 placed the new dressings on the resident's bed prior to beginning the treatment. After removing the old dressing, LPN 2 placed the discarded treatment on the resident's bed and removed her gloves. LPN 2 then applied new gloves but failed to cleanse her hands. In an interview on November 4, 2022, at 11:15 a.m., the Administrator confirmed that the staff is expected to utilize a clean field, cleanse their hands when changing gloves, and discard old treatments in a bag per facility policy. 28 Pa Code 211.10(a)(d) Resident care policies. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services.

Based on clinical record review and observation, it was determined that the facility failed to provide treatment and services to prevent further decline in range of motion and contracture for one of 36 sampled residents. (Resident 65) Findings include: Clinical record review revealed that Resident 65 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE], revealed Resident 65 was totally dependent on staff for activities of daily living and had a limitation in range of motion on both sides of upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremities. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On November 2, 2022, at various times between 9:53 a.m., and 11:03 a.m., Resident 65 was observed in a wheelchair, the palm protector was not in place on the resident's right hand. On November 2, 2022, at 1:58 p.m., the resident was observed in bed, the right palm protector was again not in place on the resident's hand. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on clinical record review, review of select facility policy, review of documentation submitted by the facility, and staff interview, it was determined that the facility failed to ensure that residents were free from mental abuse for four of nine sampled residents. (Residents 1, 3, 4, 5) This deficiency is cited as past non-compliance. Findings include: Review of the facility policy entitled, Resident Abuse & Neglect Prevention Program, Including the Elder Justice Act, dated (MONTH) 4, 2019, revealed that each resident has the right to be free from abuse, including mental abuse and that every resident in the facility shall be treated with consideration, respect, and full recognition of his/her dignity and individuality. Noted examples of mental abuse included (but were not limited to), humiliation and the failure to offer a choice when the resident was capable of making a choice. Review of documentation dated (MONTH) 21, (YEAR), from the Administrator to all facility staff revealed that electronic devices, such as cell phones, were not permitted on your person or in your work area during your work time while on duty. During an interview on (MONTH) 13, 2019, at 1:46 p.m., the Administrator and Director of Nursing confirmed that staff were prohibited from having electronic devices, including cellular telephones, in resident care areas. Clinical record review revealed that Resident 1 was admitted to the facility on (MONTH) 29, 1991, and expired in the facility on (MONTH) 29, 2019. Clinical record review revealed that Resident 3 was admitted to the facility on (MONTH) 28, (YEAR), and expired in the facility on (MONTH) 22, 2019. Clinical record review revealed that Resident 4 was admitted to the facility on (MONTH) 23, 2019, and expired in the facility on (MONTH) 22, 2019. Clinical record review revealed that Resident 5 was admitted to the facility on (MONTH) 9, (YEAR), and had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment (a periodic assessment of resident care needs), dated (MONTH) 24, 2019, indicated that the resident was unable to complete an interview to determine cognitive status and required staff assistance for activities of daily living (bathing, grooming, toileting, getting in and out of bed, etc.) A form for the resident, entitled Preferences, indicated that Resident 5 was unable to comprehend the information and the form was signed by a family member, listed as power of attorney. Review of information dated (MONTH) 24, 2019, submitted by the facility revealed that an anonymous letter had been received and the contents of the letter included photographic evidence that a nurse aide (NA1) had been taking pictures of deceased residents and was sending the photographs via text messaging to others. Screen shots of pictures were included with the letter. The screen shots included a photograph of one deceased resident (Resident 3) and one current resident (Resident 5). The letter further indicated the photos had been taken of two other deceased residents. The contents of NA1's phone had been extracted during the police investigation and confirmed that NA1 had taken photos of Resident 1 and Resident 4 when they were deceased . There was no evidence to support that the residents or responsible parties had given consent for the residents to be photographed by NA1. Review of information dated (MONTH) 12, 2019 submitted by the facility reflected that the facility had substantiated the allegation of mental abuse of Residents 1, 3, 4 and 5 by NA1. Information submitted by the facility to the Department included the following corrective actions in response to the abuse by NA1 to Residents 1, 3, 4, and 5. The facility implementation of the plan started (MONTH) 25, 2019 and is ongoing. Documentation reviewed (audits, in-service record) revealed that the plan was being monitored for implementation by supervisory staff. [NAME] All nursing staff assigned to units where NA1 was located were interviewed by the facility to determine any additional persons who may have been involved or have had knowledge of the incident. B. All facility employees were reeducated regarding resident rights, confidentiality, and privacy. New employees receive education prior to beginning job assignments. C. All facility staff were required to review and sign the facility's electronic device (including cellular telephone) directive, dated (MONTH) 22, 2019, prohibiting the possession of those items in resident care areas. D. Nursing supervisors are required to monitor for electronic device usage and complete a Cell Phone Audit Tool for random checks of employees. E. Personnel files reviewed revealed that criminal background checks were completed prior to hiring employees. Personnel files reviewed revealed all staff were properly trained on abuse prevention. Staff interviews completed on (MONTH) 12, 2019 and (MONTH) 13, 2019 during the ,[DATE] and ,[DATE] shifts revealed 39 of 39 employees were aware of all the facility abuse reporting requirements. The Personnel file for NA1 included the required background checks prior to employment and reference checks and there were no disciplinary actions involving this employee. F. Clinical record reviews of Residents 1, 3, and 4 did not reveal unusual circumstances regarding resident deaths. Clinical record review and observation of Resident 5 did not reveal any negative findings. [NAME] The facility has terminated the employment of NA1. This deficiency is cited as past non-compliance. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited [DATE], [DATE], [DATE]

Based on clinical record review and staff interview, review of select facility policy and review of documentation submitted by the facility, it was determined that the facility failed to ensure that the staff provided a resident with sufficient safety and supervision to prevent a fall that resulted in serious injury (a fractured left femur) and significant pain for one of 16 residents reviewed who were dependent on staff for assistance with transfers (Resident CR2). Findings include: Clinical record review revealed that Resident CR2 had been admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Clinical record documentation also reflected that the resident had a history of [REDACTED]. The quarterly Minimum Data Set assessment (MDS - a periodic assessment of resident needs) dated March 23, 2017, reflected that the resident could not walk, and that she was completely dependent on staff for transfers (moving to and from bed to chair, for example). Review of the information dated May 24, 2017, submitted by the facility reflected that the resident had fallen to the floor when the staff were transferring the resident from the bed to the chair using a mechanical lift (a mechanical device used to lift a resident into and out of a bed or chair). Review of the resident's care plan (a document that lists the resident's care needs and the measures that staff were to implement to meet those needs) that was in effect at the time of this fall, dated March 21, 2017, revealed that the resident had limited mobility due to polio and arthritis. The care plan reflected that the resident required two staff for transfers, and that the staff were to perform the transfers using a mechanical lift and a small sling. (The small sling is a sling-shaped device made from fabric that is used to hold the resident. The sling is placed under the resident, and is attached to the mechanical lift. The sling supports the resident's body as the lift is used to raise the resident off the bed or chair.) Review of a facility policy entitled, Hoyer Partner Lift, Use of (Hoyer Lift is another name for a mechanical lift) last revised August 2011, revealed that when transferring a resident from the bed to the chair, the staff were to use the lift to raise the resident off the bed and to move the resident to the chair. The policy indicated that staff was to then move to the back of the chair and grasp handle on back of sling and then while pulling back and up on handle of sling staff was to lower the resident into the chair. Review of the facility's investigation of the fall dated May 30, 2017, revealed that on May 24, 2017 at 9:30 a.m. two Nurse Aides (Employee 1 and Employee 2) were using the mechanical lift to transfer the resident out of the bed to the wheelchair. Facility documentation reflected in an interview on May 26, 2017 (no time), that Employee 1 reported that she had used the lift to raise the resident off the bed and to move her to the wheelchair. Employee 2 reported that as she had brought the wheelchair to the bed, the resident fell backwards and fell out over the top of the sling and onto the floor. Employee 2 reported that she had not had her hands on the sling to guide the resident to the chair because she was positioning the (wheel)chair. Based on this documentation, the staff failed to grasp the handle on the back of the sling and pull back and up, in accordance with facility policy. As a result, the resident tipped backwards and fell out of the sling. Review of nurses' notes dated May 24, 2017, at 10:41 a.m. revealed that because the resident was complaining of hip and leg pain as a result of the fall, she was transferred to the hospital. Review of hospital documentation dated that same day revealed that diagnostic tests revealed that the resident had suffered a fracture of her left femur (meaning that the long bone of the left thigh was broken) and that she also had a hematoma (a painful collection of blood in the flesh) in the left hip near the site of the fracture. Facility documentation reflected that the resident returned to the facility from the hospital on May 26, 2017. Clinical record documentation reflected that the resident suffered significant pain as a result of this fracture. For example, nurses' notes dated June 2, 2017, at 11:55 a.m. reflected that the resident yelled and had facial grimacing during morning care; on June 2, 2017, at 9:59 p.m. nurses' notes reflected grimacing when touched; on June 4, 2017, at 8:46 p.m. nurses' notes documented that the resident grimaces when touched or moved. Review of the May 2017 Medication Administration Record (MAR) revealed that in the first few days after returning from the hospital, the resident required multiple doses of Norco (a narcotic pain medication) to help relieve the pain related to the fracture. On May 28, 2017, the physician's orders [REDACTED]. Documentation on the May 2017 MAR reflected that the resident required this pain medication on May 28, 29, 30, and 31, 2017. On May 31, 2017, the physician notes reflected that the resident still had pain and was restless. Because of this, the physician increased the Roxanol to every four hours around the clock. Review of the June 2017 MAR, revealed that the the resident continued to receive the Roxanol every four hours. In a telephone interview on June 5, 2017, the Director of Nursing confirmed the resident required Roxanol to alleviate the pain associated with the fracture. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 7/15/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/15/16.