Every finding on record at Bradford Ecumenical Home, Inc

Based on review of clinical records, and staff interview, it was determined that the facility failed to inform the resident and/or resident representative in advance of the risks and benefits of psychotropic medications (medications that affect the persons mental state, emotions and behavior) and the treatment alternatives prior to initiating the administration of the medication for one of five residents reviewed for psychotropic medications (Resident R11).Findings include: Review of Resident R11's clinical record revealed an admission date of 5/15/24, with diagnoses that included depression (a persistent feeling of sadness or hopelessness that lasts for a long time and affects how a person feels, thinks, and acts, with a general sense of unhappiness that doesn't go away), and mood disorder (a condition that affects how a person feels emotionally, long lasting and can make functioning in daily life difficult.). Review of Resident R11's physician's orders revealed an order dated 5/21/25, for Zoloft (antidepressant)100 mg (milligrams) once a day. Resident R11's clinical record lacked evidence that he/she and/or his/her representative were informed in advance of the risks, benefits, and alternative treatments prior to administration of Zoloft. During an interview on 7/30/26, at 4:01 p.m. the Director of Nursing confirmed that Resident R11's clinical record lacked evidence that he/she and/or his/her representative were informed in advance of the risks, benefits, and alternative treatments prior to the administration of Zoloft. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 201.18(b)(1) Management

Based on observations, review of facility policy, and staff interview it was determined that the facility failed to utilize proper hygiene by not wearing a hair net to prevent contamination of food during the lunch food preparation. Findings include: Review of facility policy entitled Hair Restraints dated 6/10/22, indicated that food handlers that have direct contact with food shall wear hair restraints, such as hairnets, beard nets and caps that cover exposed body hair. Observation of the lunch service on 9/06/23, at 11:15 p.m. revealed that Dietary Employee E1 was not wearing a hair net when checking the temperature of the food being served. He/She did not don (put on) a hair net until reminded to do so by the supervisor after three trays of food were already checked for temperatures. During an interview on 9/06/23, at 11:30 a.m. Dietary Manager Employee E2 confirmed that Dietary Employee E1 should have been wearing a hair net to avoid the potential of contaminating the lunch meal. 28 Pa. Code 211.6(f) Dietary Services

Based on observations and review of facility policy, it was determined that the facility failed to maintain resident dignity and respect by serving meals in a timely manner to individuals seated at the same table and implementing dignified feeding practices in the main dining room. Findings include: Review of the Dining Room Service policy dated 1/1/23, revealed that Residents will be greeted and served upon arrival. Observations of the afternoon meal in the main dining room on 9/6/23, between 11:43 a.m. and 12:07 p.m. revealed the following. Observation at 11:43 a.m. on 9/6/23, revealed Resident R26 and Resident R150 were seated at the same table in the dining room together and at 11:45 a.m. Resident R26 was served his/her meal and began eating. At 11:51 a.m. Resident R26 completed his/her meal and left the dining room. Resident R150 was served his/her meal at 12:07 p.m. 22 minutes after Resident R 26 received and completed his/her meal. Observation on 9/6/23, at 11:48 a.m. revealed a table in the dining room with five residents seated together around the table. One resident was served his/her meal at 11:48 a.m. while the other four residents watched him/her eat. The last resident at the table was served at 12:06 p.m. 18 minutes after the first resident received and began eating his/her meal. During an interview on 9/6/23 at 12:52 p.m. Dietary Manager Employee E2 verified that the current process for delivering meals to residents in the dining room included that when residents arrive at the dining room, the staff take the resident's meal ticket to the kitchen and when the dietary staff get to the ticket then they prepare the meal and take it to the residents. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on observations, review of clinical records and facility policies and documentation, and staff interviews, it was determined that the facility failed to acquire, receive, and administer medications as required for one of three residents reviewed that receive medications from outside pharmacies (Resident R1). Findings include: Review of the facility Resident Handbook, received by all new admissions to the facility indicated that the facility has a contracted pharmacy specializing in providing pharmacy services to nursing homes and providing medications according to physician's orders. The handbook identified if you prefer to use your own pharmacy, it is important to make arrangements with the Director of Nursing prior to admission. It also identified that the pharmacy provider must supply the medications to be comparable with the nursing home's system for handling the delivery, storage and administration of residents medications. Review of the facility Medication Packing policy dated 1/29/21, revealed (1) solid oral medication forms (tablets and capsules) are supplied by the provider pharmacy using the agreed upon distribution system. (This may take the form of unit-dose packaging, punch cards, cassette or other packaging.) (3) Any problems noted with packaging of a medication are reported immediately to the provider pharmacy.) Review of the facility Resident Pharmacy Choice policy dated 1/29/21, identified that the nursing home will notify the resident or the resident representative, at admission and as necessary throughout the resident's stay in the facility, of the right to purchase medications from a pharmacy of the resident's choice. Review of the facility Pharmacy Selection Guidelines dated 1/29/21, revealed that each resident in long term care is free to select and use the pharmacy of his/her choice for the provision of ordered medications. It also stated that the chosen pharmacy must meet specific requirements and regulations to comply with Federal and State laws for the safety of the resident. The policy also stated that medications will only be dispensed based on the orders written in the resident's medical record by the physician, a licensed facility employee will transmit medication orders to the pharmacy, medications will be delivered directly to the facility via a pharmacist, and independent agent of the pharmacist/pharmacy, independent delivery, US mail or parcel delivery, or a physician may make the delivery. Deliveries will not be accepted via a family member. The pharmacy will dispense the medications in similar packaging system comparable with the current unit dose packaging system, .and medications and over the counter medications must be labeled according to regulations. The facility will not accept improperly labeled medication. All prescription labels will be affixed to the outside of the packaging system . Review of the facility Ordering and Receiving Non Controlled Medications policy dated 1/29/21, revealed that medications delivered from the pharmacy are received by a licensed nurse or appropriate personnel and that personnel documents the delivery on the medication delivery receipt/manifest, verifies the medications with the prescriber orders, reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor .and retains a copy of the delivery receipt . Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included dementia with behavioral disturbances, Alzheimer's disease, high blood pressure and [CONDITION(S)] (abnormal heart rhythm). Review of Resident R1's clinical record revealed that on admission the Power of Attorney (POA) signed a Medication Provider and Administration document that identified the desire to use an outside pharmacy for medications. There was no specific pharmacy designated on the form. A resident handbook was received at the time of admission with information regarding obtaining medications from outside pharmacies. The POA also signed at the time of admission the Resident Pharmacy Choice form which included the Pharmacy Selection Guidelines. Resident R1's pay status changed on 4/08/21 and the admission sheet identified that Resident R1 was private pay related to medications. During an interview on 11/03/21, at 9:42 a.m. the Nursing Home Administrator (NHA) stated that the family had not chosen a Medicare Part D (pharmacy part of Medicare) for Resident R1 and was private pay. Observation on 11/04/21, at 9:58 a.m. revealed blister packs of medications that were retrieved from the medication cart as well as in Registered Nurse (RN) Employee E1's office for Resident R1 with medication labels that had been photo copied and taped in place. It was identified that RN Employee E1 had received packs of medications from the POA from an outside local pharmacy and distributed to staff for administration to Resident R1. Blister pack medications retrieved from RN Employee E1's office included two cards containing [MEDICATION(S)] (heart medication for irregular rate) 0.125 milligrams (mg), and Zinc (mineral) 50 mg. Medications retrieved from the medication cart included: two cards with [MEDICATION(S)] 0.5 mg, one card of daily vitamin, two cards with [MEDICATION(S)] (antidepressant) 50 mg, two cards with [MEDICATION(S)] (helps keep blood from clotting) 5 mg, one card with [MEDICATION(S)] (a stool softener 100 mg, one card with Zinc 50 mg, two cards with [MEDICATION(S)] 25 mg, one card with [MEDICATION(S)] 0.125 mg, four cards with [MEDICATION(S)] (blood pressure medicine) and one card with Vitamin D3. Review of facility investigation revealed that the nursing staff were not following the protocol when accepting monthly medications from RN Employee E1 to place in the medication cart per facility documented interviews. There was no delivery slip/manifest to account for the medications delivered per the facility policy. During an interview on 11/08/21, at 9:05 a.m. the Pharmacist utilized by the POA confirmed that medications are not blister packed at their pharmacy and that medications are placed in vials for solid tablets/capsules. The facility failed to assure that Resident R1's medications were packaged, delivered, and received for administration in a manner to meet state and Federal guidelines. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services 28 Pa. Code 211.9(a)(2) Pharmacy services 28 Pa. Code 211.9(f)(2) Pharmacy services

Based on observations, review of clinical records and staff interview, it was determined that the facility failed to provide services that adhered to accepted standards of practice during a wound care dressing change for one of 23 residents (Resident R40) reviewed. Findings include: Resident R40's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Observation of wound care on 10/29/20, at 1:15 p.m. revealed the following: Licensed Practical Nurse (LPN) Employee E1 washed his/her hands in the 300/400 Unit medication room and filled two medication cups (one wet and one dry) with gauze. He/she proceeded to search through drawers in the treatment and medication carts and removed a pair of scissors. He/she then opened the packaging halfway for the foam border dressing. LPN Employee E1 then opened the packaging for the [MEDICATION NAME] dressing and began to cut the [MEDICATION NAME] dressing without cleaning the scissors and using his/her bare hands. LPN Employee E1 placed the [MEDICATION NAME] dressing on top of the opened foam border dressing pad. He/she proceeded to gather the open dressing supplies and walk down the hallway (approximately 50 feet) without covering the opened dressings. Upon entering Resident R40's room LPN Employee entered the bathroom to obtain a paper towel and then placed the dressing supplies on top of the paper towel on the tray table. He/she donned clean gloves without washing his/her hands and cleansed and dried the undressed wound. LPN Employee E1 then applied the clean dressing to the wound. He/she discarded the supplies, removed his/her gloves and washed his/her hands. During an interview at that time LPN Employee E1 confirmed the progression of these events, including carrying the opened supplies down the hall and that he/she should have changed his/her gloves and washed hands between washing the wound and applying the dressing. During an interview on 10/29/20, at 2:50 p.m. the Assistant Director of Nursing/Infection Control Nurse confirmed that LPN Employee E1 should have taken the treatment cart down the hall to prepare for Resident R40's dressing change materials instead of opening the dressing supplies in the medication room and carrying them down the hall after opening. 28 PA Code 211.10(d) Resident care policies 28 PA Code 211.12(d)(1)(2)(5) Nursing services

Based on facility policy, clinical record review and staff interview, the facility failed to ensure recommendations made from the consultant pharmacist were acted upon for two of 21 residents reviewed (Residents R26 and R32). Findings include: The facility policy Consultant Pharmacist Services Provider Requirements, dated 1/22/19, indicated that the Consultant Pharmacist would communicate recommendations for changes in medication therapy and the monitoring of medication therapy. The Face Sheet for Resident R32 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The pharmacy medication regimen reviews dated 7/24/18, 8/28/18, 10/23/18, all were requesting review of Resident R32's [MEDICATION NAME] (medication to aid in sleeping) 9 milligram (mg) physician's orders [REDACTED]. All pharmacy recommendations were not signed by the physician until 1/10/19, a period of almost six months from the original request dated 7/24/18, pharmacy review. A pharmacy medication review dated 11/27/18, requested a gradual dose reduction on the antipsychotic medication [MEDICATION NAME]. This recommendation was not signed by the physician until 1/10/19, a period of 44 days. During an interview on 5/31/19, at 8:30 a.m. the Director of Nursing confirmed that pharmacy recommendations for Resident R32 regarding duplicate drug therapies and antipsychotic medication review were not addressed by the physician until 1/10/19. The Face Sheet for Resident R26 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The pharmacy medication regimen review dated 3/26/19, requested that Resident R26's uric acid level be drawn on the next day due to Resident R26 being on anti-gout medication. The physician signed the recommendation on 5/29/19, a period of 64 days from the 3/26/19, pharmacy review. During an interview on 5/31/19, at 10:53 a.m. the Director of Nursing confirmed the pharmacy recommendation dated 3/26/19, was not addressed timely by the physician. 28 Pa. Code 211.9(i) Pharmacy services

Based on review of the Minimum Data Set (MDS-a federally mandated periodic assessment of resident care needs) and clinical records and staff interview, it was determined that the facility failed to ensure that a Quarterly MDS was completed within the required time frame for two of 21 residents (Residents R1 and R2). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) Users-Manual 3.0, dated (MONTH) (YEAR), which provides instructions and guidelines for completing MDS assessments, indicated that the Assessment Reference Date (ARD) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type. Resident R1's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R1's assessment history revealed a Quarterly MDS Assessment completed with an ARD of 1/01/2019, followed by an Annual MDS Assessment completed with an ARD of 5/17/2019. The MDS Assessments were completed 136 days apart. Resident R2's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R2's clinical record revealed a Quarterly MDS Assessment completed with an ARD of 1/09/19, followed by a Quarterly MDS Assessment completed with an ARD of 5/15/19. The Quarterly MDS Assessments were completed 128 days apart. During an interview on 5/30/19, at 12:14 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 and RNAC Employee E2 confirmed that Residents R1 and R2's Quarterly MDS Assessments were overdue and not completed in the required timeframe. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(2)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation, review of facility policy and clinical records and staff interview, it was determined that the facility failed to investigate a potential injury of unknown origin for one of 20 residents reviewed (Resident R17). Findings include: The facility policy dated 1/31/18, indicated that unexplained incidents such as skin tears, bruises, abrasions and injuries of an unknown source would be investigated as deemed appropriate. Resident R17's Annual Minimum Data Set (MDS - periodic assessment of resident care needs), dated 1/30/18, revealed an admission date of [DATE], [DIAGNOSES REDACTED]. The assessment further indicated that Resident R17 had severe cognitive impairment (mental processing), and displayed fluctuating inattention and disorganized thinking, and displayed wandering behavior and behaviors not directed at others such as pacing, disruptive sounds, or hitting/scratching self on one to three days of the assessment period. A psychiatric consult dated 4/17/18, indicated that Resident R17 was seen related to recent behavioral concerns, and an incident on 4/07/18, when Resident R17 became upset with staff while providing hands-on care and bit one of the staff assisting with care. The note further indicated that Resident R17 can become easily agitated with fell ow residents at times and has persistent delusional thoughts regarding his/her mother. On 4/18/18, at 10:08 a.m., Resident R17 was observed seated in a chair in his/her room with a swelling of the right lower lip and small open area at the center. When asked as to it's origin, Resident R17 stated No it feels okay. Resident R17's clinical record revealed that upon arising on 4/15/18, staff reported Resident R17's right lower lip to be swollen and tender; complaining of pain even with talking; and upon assessment the inner corner of lip appeared to have bluish discoloration, outer lower lip reddened/abrasion. Ice applied with some relief of pain. Clinical record review and a request for evidence of an investigation revealed that the injury/change in condition wasn't investigated by the facility. During an interview on 4/19/18, at 10:35 a.m. the Director of Nursing indicated that staff from the previous shift were not interviewed or an investigation completed in response to the discovery of the swollen lip. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 5/25/17 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 8/09/17, 5/25/17 28 Pa. Code 211.10(d) Resident care policies

Based on observations, review of clinical records and facility policy and staff interview, it was determined that the facility failed to ensure that dependent residents received the necessary assistance to maintain appropriate grooming for one of 19 residents reviewed (Resident R19). Findings include: The facility policy entitled Care of Fingernails/Toenails, dated 1/24/17, revealed that residents' nails were to be cleaned and trimmed to prevent infections. Resident R19's Significant Change Minimum Data Set (MDS-periodic assessment of resident care needs), dated 6/09/17, indicated that Resident R19 had severe cognitive (mental) impairment; [DIAGNOSES REDACTED]. Resident R19's care plan related to hygiene, dressing and grooming, indicated that Resident R19 was to be encouraged to perform upper body hygiene and grooming, as able, and assist if necessary and to assist with a weekly shower, shampoo and nail care. Observations on 8/09/17, at 4:50 p.m., revealed Resident R19 seated at a dining room table awaiting meal service. Inspection of both hands revealed that nine of ten fingernails were long, and somewhat uneven, and eight of ten fingernails had brown material under the nail beds. During an interview on 8/09/17, at the time of the observation, Nursing Assistant Employee E1 confirmed that Resident R19's nails were not appropriately groomed. 28 Pa. Code 201.18(b)(1) Management Previously cited 5/25/17 28 Pa. Code 211.11(D) Resident Care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 5/25/17

Based on review of a facility policy, electronic health records and staff interview, it was determined that the facility failed to ensure that resident orders were signed at required physician visits for three of 22 residents (Residents R4, R5 and R6). Findings include: The facility policy entitled Physician Orders/Visits, dated 1/10/17, indicated that residents would be seen by their physician every 30 days after admission for the first 90 days, then every 60 days thereafter. The policy further stated that physician orders must be signed and dated at each visit. Per the policy, physicians orders must be electronically signed and dated. Resident R4's clinical record revealed an admission date of [DATE], and [DIAGNOSES REDACTED]. Resident R4's electronic health record included physician progress notes [REDACTED]. The electronic health record lacked evidence that current physician orders were electronically re-signed at the required 60 day visits. Resident R5's clinical record revealed an admission date of [DATE], and [DIAGNOSES REDACTED]. Resident R5's electronic health record included physician progress notes [REDACTED]. The electronic health record lacked evidence that current physician orders were electronically re-signed at the required 60 day visits. Resident R6's clinical record revealed an admission date of [DATE], and [DIAGNOSES REDACTED]. Resident R6's electronic health record included physician progress notes [REDACTED]. The electronic health record lacked evidence that current physician orders were electronically re-signed at the required 60 day visits. During an interview on 5/25/17, at 10:30 a.m., the Director of Nursing confirmed that physician orders were only electronically signed by the physician on the original order, and that all resident orders were not resigned at required physician visits. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records

Based on review of facility policy and electronic health records and staff interview, it was determined that the facility failed to accurately assess a pressure ulcer in a timely manner and provide the appropriate care and treatment in relation to a pressure ulcer for one of 22 residents (Resident R12). Findings include: The Pressure Ulcer/Wound Care and Documentationpolicy, dated 1/10/17, revealed that an ulcer observation includes differentiating the type of ulcer, determining stage, describe and monitor the ulcer characteristics, monitor healing, determine if infection is present, assess and treat pain, and monitor dressing and treatment. The Resident Face Sheet revealed that Resident R12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (periodic review of resident care needs), dated 3/31/17, indicated that Resident R12 had a pressure ulcer. The 3/25/17 E-Z Graph Wound Assessment form revealed that Resident R12 had a wound on the left heel, completed by the Licensed Practical Nurse (LPN) and the LPN had put medication and a dry dressing on the wound. The medication applied to the pressure ulcer was ordered for skin tears and there was no documentation that the Registered Nurse (RN) was notified of the discovery of the pressure ulcer. Nursing documentation indicated that the LPN recorded in the nursing notes on 3/26/17, at 5:41 p.m., that on 3/25/17, Resident R12 had a small pressure sore to left heel including measurements of the wound. There was no documentation that the RN or the physician had been notified of the discovery of Resident R12's new wound. The nurse note, dated 3/27/17, indicated that the RN had staged the wound a three without a comprehensive assessment completed. A full comprehensive assessment was not documented until 3/30/17, by an RN (5 days after the discovery of the wound). During an interview on 5/24/17, at 1:50 p.m., the Registered Nurse Assessment Coordinator Employee E1 confirmed that the LPN should have notified the nurse in charge on the day that Resident R12's wound was identified and a comprehensive assessment should have been completed on Resident R12's pressure area. During an interview on 5/23/17, at 11:30 a.m., the Director of Nursing confirmed that the LPN completed an assessment of the wound, that there was no documentation that the RN on duty had been notified, that the assessment on 3/27/17, completed by the nurse was not a comprehensive assessment and that the comprehensive assessment was not documented until 3/30/17. The LPN also should not have applied the medication ordered for skin tears on the pressure ulcer. 28 pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1) Management 28 Pa. code 211.12 (d)(1)(5) Nursing services

Based on review of electronic health records, Title 49. Professional and Vocational Standards, review of job descriptions for the Registered Nurse (RN) and Licensed Practical Nurse (LPN) and facility policies and staff interviews, it was determined that the facility failed to assure that an RN conducted initial resident assessments in relation to pressure ulcers for two of 22 residents reviewed (Residents R12 and R22). Findings include: The Title 49. Professional and Vocational Standards, Department of State Chapter 21, State Board of Nursing, dated 1/15/05, indicated that under Responsibilities of the RN, 21.11 General Functions, the RN assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible and (6)(b) the RN is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered. The 21.141 Definitions practice of practical nursing reveals the performance of selected nursing acts in the care of the ill, injured or infirm under the direction of the licensed professional nurse, a licensed physician or a licensed dentist which do not require the specialized skill, judgement and knowledge required in professional nursing. The 21.145 'Functions of the LPN (Licensed Practical Nurse), the LPN participates in the planning, implementation and evaluation of nursing care using the focused assessment in settings where nursing takes place. The job description for the RN, dated 1/16/17, revealed that the RN provide nursing care to residents and direct and supervise the LPN ., shall be qualified by training and experience to assure prompt appropriate action in the event of an injury ., and shall carry out administrative directives and resident care duties according to policies and procedures and State and Federal regulations. The LPN job description, dated 1/16/17, revealed that the LPN provide nursing care under the direction and supervision of a professional RN .and carry out resident care duties according to policy and procedure . and observe and record and report to a supervisor or the physician the resident's conditions .and significant incidents. The Pressure Ulcer/Wound Care Documentation policy, dated 1/10/17, revealed that ulcer observation included differentiating the type of ulcer, determine the stage of the ulcer, describe and monitor the characteristics of the ulcer, . The Resident Face Sheet revealed Resident R12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (periodic review of resident care needs), dated 3/31/17, revealed that Resident R12 had a pressure ulcer. The E-Z Graph Wound Assessment form, dated 3/25/17, indicated that Resident R12 had a new pressure ulcer. The assessment of the measurement of the wound was conducted and signed by an LPN. A comprehensive assessment was not completed until 3/30/17 (5 days later) by an RN. During an interview on 5/23/17, at 11:30 a.m., the Director of Nursing confirmed that Resident R12 was assessed by the LPN concerning the pressure ulcer that was discovered. There was no evidence that an RN had completed the comprehensive assessment on the wound until 3/30/17. The Resident Face Sheet revealed Resident R22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The E-Z graph Wound Assessment form indicated that Resident R22 had a new wound identified on 10/14/16, and the complete assessment was completed by the LPN. There was no evidence to indicate that an RN assessed the wound with staging and measurements until 10/20/16 (six days later). During an interview on 5/25/17, at 9:17 a.m., the Director of Nursing confirmed that Resident R22's pressure ulcer was initially assessed by an LPN. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation of medication labels and staff interviews, it was determined that the facility failed to remove a medication that was expired from the medication cart on one of four nursing units, (400 Unit). Findings include: During tour on the 400 unit on [DATE] at 3:00 pm, one of five insulin pens in the med cart was found with an expired date. The label on the insulin pen indicated that it was opened on [DATE] and the expiration date was [DATE]. During interview on [DATE], at 3:00 p.m., Employee E1 confirmed that the insulin pen was expired and should have been removed from the medication cart. 28 Pa. Code 211.9(i) Pharmacy services.

Based on observations, review of facility policy and staff interview, it was determined that the facility failed to maintain sanitary practices in the kitchen. The findings include: The facility Utensil and Dishware Washing policy, dated 1/27/15, stated Allow utensils and dishes (including pots and pans) to drain and air dry. Observation in the kitchen, on 6/02/15, at 2:20 p.m., revealed two stacks of rectangular metal serving pans stacked wet. During an interview on 6/02/15, at the time of the observation, the Dietary Manager confirmed that the pans were stacked wet and should not have been. Observations on 6/03/15, from 8:35 a.m. to 8:45 a.m., revealed that Dietary Employee E2 worked with dirty dishes, then unloaded and put away clean dishes without first washing hands and changing gloves. During an interview on 6/25/15, at 9:25 a.m., the Dietary Manager confirmed that handwashing and changing gloves were required when moving from working with dirty dishes to working with clean dishes. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b) Management. 28 Pa. Code 21.6(f) Dietary Services.

Based on observations, review of facility policies and clinical records and staff interviews, it was determined that the facility failed to appropriately sanitize a multi-use medical device (BGM - blood glucose monitor) after resident use, failed to instill eye drops utilizing infection control practices, and failed to appropriately wash hands during a dressing change for three of 21 residents (Residents R1, R20, and R21). The findings include: The facility policy, entitled Blood Glucose Monitoring/Glucometer Cleaning, dated 1/10/15, indicated that BGM's would be cleaned between resident use and prior to returning to the storage tote. Resident R1's clinical record revealed [DIAGNOSES REDACTED]. During an observation of blood glucose monitoring, on 6/02/15, at 4:20 p.m., Licensed Practical Nurse (LPN) Employee E1 entered Resident R1's room with a tote containing a BGM, obtained a blood sample from Resident R1's finger with the BGM, then returned the BGM to the storage tote and placed it back in the medication drawer, before cleaning the device. During an interview at the time of the observation, LPN Employee E1 confirmed that the BGM was to be cleaned with an appropriate sanitizing product before replacing the device in the tote. The facility policy entitled Eye Drops, dated 1/10/15, indicated that when administering eye drops, the dropper tip was to be held directly over the eye, taking care to avoid touching the eye or eyelid. Resident R20's clinical record revealed [DIAGNOSES REDACTED]. During an observation of medication administration on 6/02/15, at 4:30 p.m., LPN Employee E1 proceeded to administer one drop of the Refresh Tears in each of Resident R20's eyes, touching the lower lid of each eye. During an interview at the time of the observation, LPN Employee E1 confirmed the eye dropper was not to touch the lid or eye during administration to prevent cross contamination. The facility policy entitled Handwashing, dated 1/10/15, indicated that after washing hands staff should turn off the faucet with a paper towel to avoid contaminating their hands. Review of Resident R21's clinical record revealed [DIAGNOSES REDACTED]. Observation of wound treatment to Resident R21's skin tear on 6/03/15, at 1:20 p.m., revealed that LPN Employee E1 washed his/her hands prior to the wound care, after cleaning the skin tear, and following the procedure, but turned the faucet off on each occasion with clean hands, rather than a paper towel. During an interview at the time of the observation, LPN Employee E1 confirmed that the faucet was to be turned off with a paper towel to avoid contaminating their clean hands. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy and the clinical record and staff interview, it was determined that the facility failed to notify the physician that a medication was unavailable for one of 19 residents (Resident R3). The findings include: The facility Medication Shortages policy, dated 1/27/15, stated that if a medication was unavailable from the pharmacy, nursing staff would notify the physician of the situation. The face sheet revealed that Resident R3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. During an interview on 6/04/15, at 11:20 a.m., the Director of Nursing confirmed that Resident R3 did not receive the [MEDICATION NAME] eye drops on 5/01/15, 5/02/15, 5/03/15, 5/04/15, 5/05/15, 5/06/15, 5/07/15, 5/08/15 or 5/09/15 because the medication was unavailable, and that there was no indication that the physician was notified until 5/08/15, seven days after the medication was identified as unavailable. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to consistently be accurate in the measurement of pressure ulcers to reflect healing for two of 19 residents reviewed (Residents R9 and R11). The findings include: The facility policy entitled Decubitus Care, dated 1/20/15, indicated that decubitus ulcers should be measured weekly and that the stage, location, size including length (L), width (W), and depth (D) should be documented. The policy further indicated that healing should be documented on the treatment sheet, nurses notes and care plan. Resident R9's clinical record revealed an admission date of [DATE], and [DIAGNOSES REDACTED]. The clinical record further indicated the development of a Stage II pressure ulcer (partial thickness loss of skin) of the left great toe joint on 5/13/15. A physician order, dated 5/13/15, indicated the wound was to be measured weekly. Review of Resident R9's weekly pressure ulcer measurements revealed the following measurements: 5/13/15 0.7 cm (L) by 0.6 cm (W) by 0 cm (D) Stage II, new 5/18/15 0.4 cm (L) by 0.3 cm (W) by 0 cm (D) Stage II, improving 5/24/15 0.3 cm (L) by 0.2 cm (W) by 0 cm (D) Stage II, improving, hard callous surrounding wound measuring 0.8 cm (L) by 0.8 cm (W) 6/01/15 0.8 cm (L) by 0.8 cm (W) by 0 cm (D) Stage II, improving, getting smaller (double previous measurement) During an interview on 6/04/15, at 1:00 p.m., Registered Nurse Assessment Coordinator E3 confirmed the measurements of Resident R9's wound, on 6/01/15, reflected an increase in size between 5/24/15 and 6/01/15, but likely reflected measurements of the surrounding callous and not the open area of the wound. Resident 11's clinical record revealed an admission date of [DATE], and [DIAGNOSES REDACTED]., and dementia. The clinical record further revealed the identification of a pressure ulcer of the coccyx on 2/06/15, following a hospital admission. Review of Resident R11's pressure ulcer measurements revealed the following: 2/08/15 1.3 cm (L) by 0.7 cm (W) by 0 cm (D) Stage II, new 2/17/15 1 cm (L) by 0.5 cm (W) by 0.1 cm (D) Stage II, improving 2/23/15 1.5 cm (L) by 0.8 cm (W), by 0 (D) Not stageable, unchanged 3/02/15 8 cm (L) by 5 cm (W), by no (D); and a second wound documented as left and lateral to the coccyx wound, measuring 1.8 cm (L) and .7 cm (W), by 0 (D), New, previously documented, improving (five times larger than previous measurement) 3/09/15 7.5 cm (L) by 2.8 cm (W), 0 cm (D) Stage II, improving 3/16/15 7 cm (L) by 3 cm (W) No depth documented Stage II, improving 3/23/15 7 cm (L) by 2.5 cm (W) 0 cm (D) Stage II, improving, no open areas - base is pink scar tissue During an interview on 6/04/15, at 1:30 p.m., the Director of Nursing confirmed that Resident R11's pressure ulcer measurements markedly increased from 2/23/15, to 3/02/15, and was likely related to staff variation in measurement techniques (measuring open areas, verses healing/healed areas). 28 Pa. Code 211.12d)(1)(5) Nursing services.

Based on review of facility policy and the clinical record and staff interview, it was determined that the facility failed to provide pharmacy services for the provision of medication for one of 19 residents (Resident R3). The findings include: The facility Medication Shortages policy, dated 1/27/15, stated that if a medication was unavailable from the pharmacy, the facility nurse must make every effort to ensure that a medication ordered for a resident is available to meet their needs, that the pharmacy would notify staff that the physician ordered medication was unavailable and suggest alternative and comparable drugs that are available. Nursing staff would notify the physician of the situation and obtain a new order. The face sheet revealed that Resident R3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. During an interview on 6/04/15, at 11:20 a.m., the Director of Nursing confirmed that the pharmacy did not provide Resident R3's medication and that Resident R3 did not receive the Lumigan eye drops on 5/01/15, 5/02/15, 5/03/15, 5/04/15, 5/05/15, 5/06/15, 5/07/15, 5/08/15 or 5/09/15 because the medication was unavailable. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12(c)(d)(5) Nursing services.

Based on record review and resident and staff interviews, it was determined that the facility failed to invite and involve residents and/or their responsible parties in care plan meetings for eight of 27 residents reviewed (Residents R10, R11, R12, R23, R24, R25, R26 and R27). The findings include: Review of resident care plan attendance records for Resident R10 revealed that quarterly care plan meetings were held on 3/20/12, 6/12/12, 9/04/12, 11/13/12, 2/11/13 and 4/30/13. Documentation indicated that Resident R10 did not attend due to cognitive impairment. The attendance record for the care plan meetings indicated that Resident R10's responsible party did not attend. There was no documentation that Resident R10's responsible party was invited to attend the above listed care plan meetings. Review of resident care plan attendance records for Resident R11 revealed that quarterly care plan meetings were held on 5/01/12, 7/24/12, 10/12/12, 1/09/13 and 4/02/13. The attendance records for the care plan meetings indicated that Resident R11 and/or the resident's responsible party did not attend. There was no documentation that Resident R11 or the resident's responsible party was invited to the above listed care plan meetings. Review of resident care plan attendance records for Resident R12 revealed that quarterly care plan meetings were held on 9/11/12, 12/04/12, 2/19/13 and 5/14/13. Documentation indicated that Resident R12 did not attend due to cognitive impairment. There was no documentation that Resident R12's responsible party was invited to the above listed care plan meetings. During a group interview of alert and oriented residents, on 6/05/13, from 10:00 a.m. to 10:40 a.m., Residents R23, R24, R25, R26 and R27 stated that they are not invited to their quarterly care plan meetings. During an interview on 6/06/13, at 8:40 a.m., Resident Care Coordinator Employee E3 confirmed that the responsible party is not invited to attend the quarterly care plan meetings, and that there is no documentation to support that the residents are invited to attend their quarterly care plan meetings. 28 Pa. Code 211.11(e) Resident care plan.

Based on observations and staff interviews, it was determined that the facility failed to maintain a sanitary environment on four of four wings (Wings 100-200-300 and 400). The findings include: Observations on the 100, 200, and 300 wings from 3:20 p.m. to 4:00 p.m., revealed the following: Grab bars for the toilets in all resident bathrooms were silver colored and had brown discoloration. The floor tiles in Room 306 bathroom were discolored. Room 306 had a discolored tattered and torn fall mat near the window bed. Room 311 had loose cove base extending along the wall facing the hallway and the right side of the room. During an interview on 6/04/13, from 3:20 p.m. to 4:00 p.m., Licensed Practical Nurse Employee E7 confirmed the brown stained toilet grab bars in Wings 100, 200 and 300, the discolored bathroom floor in room 306, the dirty and torn fall mat and the loose cove base in room 311. Observations of 400 Wing on 6/04/13, at 3:50 p.m., revealed the following: The floor tiles in the bathroom of room 412 had a dark discoloration in front of the toilet. The grab bars for the toilet in the bathroom of room 412 were silver colored and had brown discoloration. During an interview on 6/04/13, at 3:50 p.m., Registered Nurse Employee E2 confirmed the discolored floor and grab bars in the bathroom of room 412. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 207.2(a) Administrator's responsibility.