Every finding on record at Bradford Manor Nursing and Rehab

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen and change/date oxygen tubing and humidifier bottle according to physician's orders for one of two residents reviewed for respiratory services (Resident R84).Findings include: Review of facility policy entitled Respiratory Services dated 12/8/24, indicated oxygen cannulas [oxygen tubing that has prongs that go into the nostrils and loops around the ears to secure in place to ensure adequate oxygen delivery] frequency of change weekly or PRN (as needed), prefilled humidifier bottles frequency of change weekly or PRN when empty. Review of Resident R84's clinical record revealed an admission date of 11/10/23, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), hypertension (high blood pressure), and heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues). Review of Resident R84's physician's orders revealed orders for oxygen at two liters per minute per nasal cannula as needed and oxygen maintenance change O2 [oxygen] tubing and supply bag weekly. change water jug weekly. Review of Resident R84's vital sign records revealed that he/she used his/her oxygen 21 times between 6/23/25, and 7/29/25. Observations on 7/28/25, at 2:00 p.m. revealed a nasal cannula attached to an oxygen tank on the back of Resident R84's wheelchair with no date and a humidifier water bottle attached to an oxygen concentrator that was dated 6/23/25. Further observations on 7/29/25, at 8:30 a.m., 9:28 a.m., and again at 12:25 p.m. revealed the nasal cannula remained attached to the oxygen tank with no date and the humidifier water bottle attached to the concentrator remained dated 6/23/25. During an interview on 7/29/25, at 12:25 p.m. Licensed Practical Nurse Employee E2 confirmed that Resident R84's nasal cannula lacked a date, and the humidifier water bottle was dated 6/23/25. He/she also confirmed that the nasal cannula and the humidifier water bottle should have been changed. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies and clinical records, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) during wound care for one of three residents that require EBP's (Resident R9) and failed to provide appropriate infection control measures regarding a urinary catheter (a tube placed and held in the bladder to drain urine) for one of three residents reviewed with a catheter (Resident R4).Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions, dated 12/08/24, are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDRO). It also indicated that gloves and gown are to be applied prior to performing the high contact resident care activities, which includes wound care. Review of facility policy entitled Infection Control dated 12/8/24, indicated implementation of control measures, the prevention and spread of health care associated infections are accomplished using standard precautions and other barriers, and staff and resident education focuses on risk of infection and practices to decrease this risk. Review of Resident R9's clinical record revealed an admission date of 3/16/23, with diagnoses that included diabetes mellitus (condition where the body doesn't produce enough insulin to control blood sugar levels), diabetic neuropathy, diabetic foot ulcer. and chronic kidney disease. Review of Resident R9's physician's orders dated 6/16/25, included an order to cleanse the right heel diabetic ulcer and apply Dakins solution gauze to the wound and cover with dry dressing. Observation of wound care on 7/29/25, at 12:20 p.m. revealed that Licensed Practical Nurse (LPN) Employee E1 entered Resident R9's room without donning (putting on) a gown. Resident R9's room had a sign above the bed indicating EBP's and gloves and gowns were available in the resident's room. During an interview on 7/29/25, at 12:25 p.m. LPN Employee E1 confirmed he/she did not don a gown prior to entering Resident R9's room. Review of Resident R4's clinical record revealed an admission date of 6/10/25, with diagnoses that included Benign prostatic hyperplasia (a noncancerous condition that causes the prostate gland to become enlarged and cause difficulty urinating) chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), and hypertension (high blood pressure). Review of Resident R4's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated 7/4/25, revealed that Resident R4 had an indwelling urinary catheter. Observations on 7/29/25, at 8:35 a.m., 9:30 a.m., and again at 12:10 p.m. revealed Resident R4's urinary drainage bag lying flat on the floor with the drainage spout (the part of the urinary bag that opens to empty urine from the bag) facing down and touching the floor. During an interview on 7/29/25, at 12:26 p.m. LPN Employee E2 confirmed that the urinary drainage bag was lying on the floor face down and also confirmed that the urinary drainage bag should not be on the floor. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for three of four residents reviewed (Residents R2, R6, and R84). Findings include: Review of facility policy entitled Admission, Transfer, Discharge and Room Change Policy dated 12/8/24, indicated The Manor is required to provide sufficient Preparation. to ensure safe and orderly transfer. and transfers. are documented in the residents clinical record. Review of Resident R2's clinical record revealed an admission date of 7/23/23, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), and chronic obstructive pulmonary disease (COPD-when your lungs do not have adequate air flow). Resident R2's clinical record revealed a progress note dated 4/16/25, at 8:31p.m. indicating a transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Review of Resident R6's clinical record revealed an admission date of 10/18/23, with diagnoses that included peripheral vascular disease (a condition in the circulatory system which reduces blood flow to the limbs due to narrowing vessels), hyperlipidemia (high cholesterol), and hypertension (high blood pressure). Resident R6's clinical record revealed progress notes dated 6/5/25, at 6:20 a.m. and 6/28/25, at 6:06 p.m. indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. Review of Resident R84's clinical record revealed an admission date of 11/10/23, with diagnoses that included COPD, hypertension, and heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues). Resident R84's clinical record revealed a progress note dated 6/24/25, at 1:12p.m. indicating transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider. During an interview on 7/30/25, at 1:30 p.m. the Director of Nursing confirmed that the clinical records for Residents R2, R6 and R84 lacked evidence that the necessary clinical information was provided to the receiving healthcare provider upon transfer and when transfers occur clinical information should be provided to the receiving healthcare provider. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3) (2) Resident rights

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans by the target date and to reflect the current necessary care and services for four of 20 residents reviewed (Resident R4, R11, R78, and R84).Findings include: Review of facility policy entitled Care Plan Policy dated 12/8/24, indicated The Manor will develop a comprehensive person centered care plan for each resident. and Periodically reviewed and revised. Review of Resident R4's clinical record revealed an admission date of 6/10/25, with diagnoses that included chronic obstructive pulmonary disease (COPD-when your lungs do not have adequate air flow), and hypertension (high blood pressure). Review of Resident R4's person centered care plans revealed a care plan for catheter with a target date (a date on which the care plan should have been revised) of 6/30/25. Review of Resident R11's clinical record revealed an admission date of 12/17/24, with diagnoses that included hyperlipidemia (high cholesterol) and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Review of Resident R11's person centered care plans revealed all his/her care plans with a target date of 6/26/25. Review of Resident R78's clinical record revealed an admission date of 6/7/24, with diagnoses that included COPD, hyperlipidemia, and type II diabetes (the pancreas does not make enough insulin to control blood sugar levels). Review of Resident R78's person centered care plans revealed all his/her care plans with a target date of 7/17/25. Review of Resident R84's clinical record revealed an admission date of 11/10/23, with diagnoses that included COPD, hypertension (high blood pressure), and heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues). Review of Resident R84's person centered care plans revealed all his/her care plans with a target date of 7/10/25. During an interview on 7/30/25, at 1:30 p.m. the Director of Nursing confirmed that Residents R4, R11, R78, and R84's care plans were beyond their target dates and that the care plans should have been updated by the target dates. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive person-centered care plans for a resident with Post Traumatic Stress Disorder (PTSD), and for a resident requiring oxygen therapy that included measurable objectives and timetables to meet a resident's needs for two of 20 residents reviewed (Residents R8 and R84). Findings include: A facility policy entitled, Care Plan, dated 12/08/24, indicated the facility will develop a comprehensive person centered care plan for each resident that includes measurable objective and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, and include: services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; be developed within seven days after the completion of the comprehensive assessment, prepared by the interdisciplinary team, be periodically reviewed and revised by a team of qualified personal after each assessment, and provide services that meet professional standards of quality. Review of Resident R8's clinical record revealed an admission date of 4/08/25, with diagnoses that included Parkinson’s disease, PTSD, anxiety, and depression. Review of Resident R8's person centered plans of care lacked evidence that a plan of care for PTSD was developed. During an interview on 7/30/25, at 11:45 a.m. the Nursing Home Administrator confirmed that a PTSD care plan was not developed for Resident R8. Review of Resident R84’s clinical record revealed an admission date of 11/10/23, with diagnoses that include chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), hypertension (high blood pressure), and heart failure (the inability of the heart to maintain an adequate supply of blood to organs and tissues). Review of Resident R84’s person centered plans of care lacked evidence that a plan of care for respiratory care with use of oxygen was developed. During an interview on 7/30/25, at 1:30 p.m. the Director of Nursing (DON) confirmed that a plan of care for respiratory care with use of oxygen was not developed for Resident R84. He/she also confirmed that a respiratory plan of care with use of oxygen should have been developed. 28 Pa. Code 201.14 (a) Responsibility of Licensee 28 Pa. Code 201.18 (b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to implement infection control practices regarding Enhanced Barrier Precautions (EBPs-additional infection control precautions put in place during high contact care activities for individuals who have an increased risk of multi-drug resident organisms [MDROs] or who are colonized/infected with MDROs) for residents with a gastric feeding tube (a medical device used to provide nutrition and/or medications when a person cannot swallow or take anything by mouth) and for residents with indwelling urinary catheters (tubing inserted into the bladder to drain urine into a bag) for six of six residents reviewed (Residents R170, R59, R37, R41, R19, and R58). Findings include: Review of the facility policy entitled Enhanced Barrier Precautions dated 12/7/23, revealed, Enhanced barrier precautions may be considered for the following situations: Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status: High contact care activities: Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. Resident R170's clinical record revealed an admitted [DATE], with diagnoses that included sepsis (a life threatening complication of an infection), hypertension (high blood pressure), and chronic kidney disease. Review of Resident R170's clinical record revealed a physician's order dated 8/23/24, for nursing staff to complete gastric tube site care every day on daylight shift. This order is considered a high contact care activity. Resident R59's clinical record revealed an admitted [DATE], with diagnoses that included hemiplegia/hemiparesis (complete paralysis and partial weakness on non-dominant side), hyperlipidemia (high cholesterol), and hypertension (high blood pressure). Review of Resident R59's clinical record revealed a physician's order dated 12/28/23, for nursing staff to cleanse the gastric tube site with wound cleanser, pat dry, and apply a T-Sponge (dressing used to absorb drainage) every day on daylight shift. This order is considered a high contact care activity. Resident R37's clinical record revealed an admitted [DATE], with diagnoses that included neuromuscular dysfunction of the bladder (nerves and muscles of the bladder do not work properly) and chronic kidney disease. Review of Resident R37's clinical record revealed a physician's order dated 11/1/23, for nursing staff to provide indwelling catheter care every shift. This order is considered a high contact care activity. Resident R41's clinical record revealed an admitted [DATE], with diagnoses that included overactive bladder, hypertension, and end stage renal disease (a condition in which the kidneys are no longer able to remove waste and balance fluids). Review of Resident R41's clinical record revealed a physician's order dated 3/31/24, for nursing staff to provide indwelling catheter care every shift. This order is considered a high contact care activity. Resident R19's clinical record revealed an admitted [DATE], with diagnoses that included neuromuscular dysfunction of the bladder (nerves and muscles of the bladder do not work properly), multiple sclerosis (a disease in which the body attacks the protective covering of the nerves), and anxiety. Review of Resident R19's clinical record revealed a physician's order dated 11/15/22, for nursing staff to provide indwelling catheter care every shift. This order is considered a high contact care activity. Resident R58's clinical record revealed an admitted [DATE], with diagnoses that included neuromuscular dysfunction of the bladder, hypertension, and chronic kidney disease. Review of Resident R58's clinical record revealed a physician's order dated 12/27/23, for nursing staff to provide indwelling catheter care every shift. This order is considered a high contact care activity. Observations made on 8/28/24, at approximately 10:25 a.m. revealed that there were not any EBPs in place for any residents listed above who have an indwelling medical device and require high contact care activities to be completed by nursing staff. During an interview at that time, the Director of Nursing confirmed that EBPs were not in place for all residents listed above, and employees should be wearing gloves and gowns during high contact care activities with indwelling medical devices such as gastric feeding tubes and indwelling urinary catheters. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to assure physician's orders, resident's Pennsylvania Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments), and paper charts were consistent for one of 18 residents reviewed (Resident R41). Findings include: The facility policy entitled Pennsylvania Orders for Life-Sustaining Treatment (POLST) dated [DATE], indicated that if a person is admitted with an existing POLST, it will be honored. If a person does not have one on admission, one will be completed with the person or surrogate. Resident R41's clinical record revealed an admitted [DATE], with diagnoses including end stage renal disease, Parkinson's disease and adult failure to thrive. Resident R41's physician's orders dated [DATE], revealed an order for Do Not Resuscitate (Allow Natural Death) - DNR. Resident R41's clinical record revealed a POLST dated [DATE], that identified Resident R41 requested Cardiopulmonary Resuscitation (CPR-measures performed to help sustain life), Comfort Measures Only. Resident R41's care plan dated [DATE], with a revision date of [DATE], indicated the Code Status as DNR. During an interview on [DATE], at 1:55 p.m. the Nursing Home Administrator confirmed Resident R41 physician's orders, POLST, and care plan were not consistent with each other. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.10(c) Resident care policies

Based on review of clinical records and facility documentation, and staff interview, it was determined that the facility failed to complete the Minimum Data Set (MDS-periodic assessment of resident care needs) to accurately reflect the resident's status at the time of the assessment for one of 18 residents reviewed (Resident R15). Findings include: Review of Resident R15's clinical record revealed an admitted [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction (paralysis and muscle weakness or partial paralysis from a stroke), depression, heart failure and high blood pressure. Review of the Quarterly MDS dated [DATE], Health Conditions Section J1900 C. Number of Falls since Admission or Prior assessment- Major Injury, indicated one. Review of Resident R15's progress notes revealed that on 6/30/24, Resident R15 was observed on the floor in his/her room, resident was assessed and noted to have a bruise to the mid back, Resident R15 did not go to the hospital for treatment. During an interview on 8/29/24, at 10:45 a.m. the Nursing Home Administrator confirmed that Section J1900 of the Quarterly MDS dated [DATE], was incorrectly coded for Resident R15 regarding a fall with major injury. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of clinical records, and staff interviews, it was determined that the facility failed to provide a clinical rationale and duration for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for one of six residents reviewed for psychotropic medications (Resident R65). Findings include: Resident R65's clinical record revealed an admitted [DATE], with diagnoses that included pneumonia (an infection in the lungs), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), chronic obstructive pulmonary disease (when your lungs do not have adequate air flow) and chronic respiratory failure (a condition where your lungs don't exchange air properly). Review of Resident R65's medication orders revealed a physician's order dated 8/21/24, to administer Hydroxyzine (anti-anxiety) 25 milligrams (mg) by mouth every 12 hours as needed for anxiety. The medication order lacked the required stop date within 14 days or a clinical rational for continuing beyond 14 days. During an interview on 8/29/24, at 11:35 a.m. with the Registered Nurse Employee E1 he/she confirmed that Resident R65's Hydroxyzine order lacked the required stop date within 14 days and a clinical rationale for continued use beyond 14 days. He/she also confirmed that the medication should have a clinical rationale and duration to continue beyond 14 days. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders for one of one residents reviewed for respiratory services (Resident R65). Findings include: Review of facility policy dated 12/7/23, entitled Nursing Services indicated that the Registered Nurse Assures that nursing care personal are following the residents care plan. Resident R65's clinical record revealed an admitted [DATE], with diagnoses that included pneumonia (an infection in the lungs), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), chronic obstructive pulmonary disease (when your lungs do not have adequate air flow) and chronic respiratory failure (a condition where your lungs don't exchange air properly). Review of Resident R65's Care Plan revealed a care plan for oxygen therapy with an intervention of oxygen 3 liters per minute (lpm) via nasal cannula (tubing with small prongs that fit into the nostrils to deliver oxygen) per physician's orders. Review of Resident R65's clinical record revealed a physician's order dated 7/24/24, for Oxygen via Nasal Cannula 3 lpm as needed (PRN). Observation on 8/27/24, at 1:00 p.m. revealed Resident R65 sitting in his/her wheelchair with supplemental oxygen in place and the oxygen concentrator liter flow set at 4 lpm. Observation on 8/29/24, at 8:15 a.m. revealed Resident R65 sitting on his/her bed with supplemental oxygen in place and the oxygen concentrator liter flow set at 4 lpm. Observation on 8/29/24, at 8:40 a.m. revealed Resident R65 laying in his/her bed with supplemental oxygen in place and the oxygen concentrator liter flow set at 4 lpm. During an interview on 8/29/24, at 8:45 a.m. Licensed Practical Nurse Employee E2 confirmed that Resident R65's oxygen concentrator was on and set at 4 lpm and was not in accordance with the physician's order dated 7/24/24, for oxygen at 3 lpm PRN. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to ensure that a resident with limited range of motion received physician ordered treatment and services to prevent further decrease in range of motion for one of 18 residents reviewed (Resident R59). Findings include: Review of facility policy entitled Specialized Rehabilitative/Restorative Services dated 12/7/23, indicated Assisting residents ., to use their prosthetic devices . and Review of facility Skills Competency/Orientation Checklist for facility staff under competency performance criteria revealed Splint/Prosthesis and Demonstrates ability to read and implement a restorative plan of care. Review of Resident R59's clinical record revealed an admitted [DATE], with diagnoses that included hemiplegia (a condition where a person is paralyzed and unable to move one side of their body), hypertension (high blood pressure), and hyperlipidemia (high cholesterol). Review of Resident R59's clinical record revealed a physician's order dated 12/28/23, that identified an order for hand splint to left hand may remove for hygiene. Further review of clinical record revealed a care plan for Activities of Daily Living (ADL) with an intervention of left hand splint for contracture management. Observation on 8/28/24, at 8:20 a.m. revealed resident in his/he bed with left hand splint laying on the nightstand. Observation on 8/28/24, at 10:35 a.m. revealed resident in his/he bed with left hand splint laying on the nightstand. Observation on 8/29/24, at 8:40 a.m. revealed resident in his/he bed with left hand splint laying on the nightstand. During an interview on 8/29/24, at 8:45 a.m. Licensed Practical Nurse (LPN) Employee E2 confirmed that Resident R59's left hand splint was laying on the nightstand. LPN Employee E2 also confirmed that the resident's left hand splint should be on resident's left hand except during hygiene. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of a facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of two refrigerators reviewed (Resident Pantry at main nurse's station, B hall). Findings include: Review of the facility policy entitled Food Brought by Family/Visitors dated 12/13/22, indicated all food requiring refrigeration must be dated and labeled with the resident's name. Review of the facility policy entitled Infection Control/Food Safety dated 12/13/22, indicated only resident food items are stored in nutrition services refrigerators. Observation on 9/19/23, at 5:56 p.m. revealed a refrigerator in the resident pantry at the main nurse's station that contained a bottle of cola that was half empty without a name or date. Observation on 9/19/23, at 5:56 p.m. revealed a freezer in the resident pantry at the main nurse's station containing ice packs that were used for treatments on resident body parts and also ice cream in the same freezer. During an interview at the time of observation with Licensed Practical Nurse Employee E2 he/she confirmed that items in the resident pantry refrigerator should have names and dates on them and that ice packs used on resident's body parts should not be stored in the resident pantry freezer. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of clinical records and facility documents, and resident and staff interviews, it was determined that the facility failed to provide appropriate behavioral health services/interventions to address behaviors for one of 17 residents (Resident R2). Findings include: Review of the facility's Skilled Nursing Facility Resident Handbook dated 3/2017, reviewed 12/13/22, Code of Conduct section indicated that all residents, family members and visitors should act and behave in a manner that is both respectful of and courteous towards the other residents living in the home as well as towards the staff members who provide care and services to such residents on a daily basis. Review of Resident R2's clinical record revealed an admitted [DATE], with diagnoses including left-sided weakness related to stroke, obesity, depression, anxiety, high blood pressure, and Type 2 Diabetes (condition that affects how the body uses glucose [sugar]). The clinical record revealed that Resident R2 received his/her Skilled Nursing Facility Handbook on 5/13/19. Review of Resident R2's most recent Minimum Data Set (MDS- periodic evaluation of resident health and mental status) dated 8/07/23, Section C0500 Cognitive Patterns revealed that his/her Brief Interview for Mental Status (BIMS) scored a 13 (cognitively intact), Section E0100 revealed no hallucinations or delusions, and Section E0200 verbal symptoms directed towards others and not directed toward others occurred one to three days in a seven day lookback period. Further review of Resident R2's clinical record revealed a care plan entitled, potential to demonstrate physical/verbal behaviors related to anger and dated 10/21/19. Review of Interdisciplinary Meeting documentation dated 7/27/23, and 8/09/23, revealed that Resident R2 was in attendance and that the Code of Conduct was reviewed. Review of Resident R2's Behavior Monitoring and Intervention Report from 9/01/23, to 9/21/23 (20 days), revealed nine incidents of displaying targeted behaviors and the attempted interventions were ineffective (9/03/23, 9/13/23 twice, 9/14/23, 9/15/23, 9/16/23, 9/17/23, 9/19/23, and 9/20/23). Review of facility documents provided on 9/21/23, from the Behavior Committee Meeting Minutes revealed: that on 5/11/23, Resident R2 exhibited behaviors 34 times in a 14-day lookback and the recommendation was to respond timely, communicate and educate; on 7/18/23, Resident R2 exhibited behaviors 52 times in a 30-day lookback and the recommendation was to have night staff get music and football on his/her TV. Review of a contracted psychological staff evaluation of Resident R2 dated 5/20/23, revealed that Resident R2 had reported significant symptoms related to depression, and to follow-up in one month or sooner if needed. There was no evidence that Resident R2 was evaluated as ordered. Review of Resident R2's clinical record revealed the following sample of departmental progress notes: -7/24/23, 2:01 p.m. yelling out with repetitive commands fix my TV, change the channel, find me a football game, 'empty my urinal, continued to yell out while repeatedly pushing his call bell. -8/02/23, 7:46 p.m. yelling out help several times, provided call light, urinal, and TV remote. Resident continued to yell at staff calling them names, refusing medications stating, I don't want that s*** and threatened to call the state when staff was going to leave the room. -8/02/23, 8:11 p.m. yelling shut the f****** light off, you people are stupid, I am turning you guys in tomorrow fat f****** cow, stupid b******. -8/02/23, 8:15 p.m. yelling you mother f****** liars, you stupid b******, and surrounding residents are upset and yelling at him/her to shut up, Resident R2 responding you shut the f*** up a*******. -8/02/23, 8:17 p.m. yelling die b******, go to hell now, f******die, get outta here you f****** liar. -8/04/23, 9:20 a.m. yelling for additional regular sugar for his/her cereal after having received two packets, when educated on diagnosis of Diabetes, Resident R2 stated I know. I don't care. Yelling out again after breakfast for staff to remove the tray, provided the call bell and continued to yell out for staff assistance. -8/19/23. 10:18 p.m. yelling and pushing call light continuously, getting very angry about not being able to watch football, peanut butter and jelly sandwiches. -8/22/23, 9:47 a.m. yelling out for the spoon, more sugar, straw, cutting up meat, moving the cup, stated understanding to use call bell but continued to yell. -9/16/23, 6:24 a.m. yelling at staff fat m*****f*****. Interviews between 9/19/23, and 9/21/23, with six alert and oriented residents with rooms near to Resident R2 confirmed the following: -As long as staff stops what they are doing and get to him/her quick enough there is a chance that the yelling and swearing will stop. -There have been times they stop getting me ready to go to him/her. If not he/she will yell and swear all evening. -It's embarrassing and offensive when he/she yells like that. -I just feel so bad for the staff, they take the brunt of it. -I don't talk like that, and don't feel I should hear others talk like that, especially screaming it in the hallways. -The administration has not done anything to stop the vulgar language from him/her. Staff are verbally abused daily. -I am hard of hearing, but I can hear that he/she is upset often and screams loudly in the hallway and from his/her room at staff and other residents. During an interview on 9/21/23, at 2:30 p.m. the Director of Nursing confirmed that this is who the resident is, staff are doing better about getting to him/her quicker, there's nothing they can do about him/her, staff do attempt the interventions, and that there is nowhere to turn when they fail, and that they all realize this is just the way he/she is and there is no behavior management program in place. 28 Pa. Code 201.18 (b)(1)(2) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and facility staff education documents, observations and staff interviews, it was determined that the facility failed to prevent the potential of cross-contamination for one of 17 residents (Resident 28). Findings include: Review of Resident R28's clinical record revealed an admitted [DATE], with diagnoses that included Dementia (a disease of the brain that is characterized by impairment of judgment and memory loss), Depression, Diabetes Mellitus (condition that affects how the body uses glucose [sugar]), and history of a Traumatic Brain Injury. Review of facility staff education entitled, Skills Demonstration/Evaluation-Insulin Pens dated 11/2013, stated Steps in the Performance Criteria 1. Washes hands and applies gloves. 2. Attaching the needle. 3. Removing the needle cap. 4. Checking the flow of delivery device (air shot). 5. Select the dose prescribed. 6. 2-unit PRIME every time. 7. Push the needle so hub touches skin at a 90-degree angle. 8. Inject dose. 9. Press the push button all the way down-dial will read zero. 10. Hold needle in place for 6 seconds. 11. Withdraw the need from the skin. 12. Recognize the safety lock mechanism has activated automatically. 13. After the injection, remove the needle from the device without replacing the cap. 14. Dispose of needle in a sharp's container. 15. Remove gloves and washes hands. 16. Label prefilled insulin pen with resident's name and date opened and store in appropriate place. During an observation of medication administration on 9/20/23, at 11:00 a.m. Licensed Practical Nurse (LPN) Employee E1 did not apply gloves prior to the administration of insulin for Resident R28. During an interview on 9/20/23, at 11:05 p.m. LPN Employee E1 confirmed that he/she failed to apply gloves prior to the administration of insulin for Resident R28. During an interview on 9/20/23, at approximately 2:15 p.m. the Director of Nursing confirmed that LPN Employee E1 should have applied gloves for insulin administration to prevent the potential of cross-contamination. 28 Pa. Code 211.10(d) Resident care policies 28 Pa Code 21.12 (d)(1)(5) Nursing services

Based on review of facility policy and clinical records and staff interview, it was determined that facility staff failed to maintain complete and accurate clinical records for one of 17 residents reviewed (Resident R54). Findings include: Review of facility policy Documentation Policy, dated 12/13/22, indicated that the facility will provide a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc It also indicated there would be the appropriate information to assist the physician in ordering medications, treatments and diet. Review of Resident R54's clinical record revealed an admitted [DATE], with diagnoses that included pneumonia, diabetes, esophagus cancer and adult failure to thrive. Review of a Nursing Admission Screener for Resident R54 dated 8/19/23, revealed a coccyx (small triangular bone forming the lower extremity of the spinal column) pressure area that measured 4.6 centimeters (cm) x 3.0 cm x 1.6 cm Stage III (Full-thickness tissue loss). Review of the Nursing Wound Documentation records for Resident R54 after the admission screener revealed the following: 8/22/23, revealed Resident R54 had an Unstageable (an ulcer that has full-thickness tissue loss but is either covered by extensive necrotic [dead] tissue or by an eschar [hard crust or scab]) sacrum (a large, triangular bone at the base of the spine that forms by the fusing of the sacral vertebrae) pressure area measuring 7.0 cm x 7.5 cm x 0.1 cm 8/29/23, revealed Resident R54's sacrum pressure area measuring 4.0 cm x 2.0 cm x 0.1 cm. Unstageable 9/05/23, revealed Resident R54's sacrum pressure area measuring 4.2 cm x 2.5 cm x 0.1 cm Unstageable 9/12/23, revealed Resident R54's sacrum pressure area measuring 3.5 cm x 2.0 cm x 0.1 cm Stage III 9/19/23, revealed Resident R54's coccyx pressure area measuring 3.5 cm x 1.0 cm x 0.1 cm Stage III Observation of Resident R54's pressure ulcer area on 9/21/23, at 1:30 p.m revealed the sacrum to have a Stage III ulcer. During an interview on 9/21/23, at 11:00 a.m. the Regional Clinical Specialist confirmed that the clinical record lacked consistent documentation regarding Resident R54's sacrum wound regarding measurements and location of the wound 28 Pa. Code 211.5 (f) Clinical records 28 Pa. Code 211.12(d)(1)(3) Nursing services

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current necessary care and services for one of 17 residents reviewed (Resident R2). Findings include: Review of a facility policy entitled Comprehensive Care Plan dated 12/13/22, indicated that services are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and will be periodically reviewed and revised by a team of qualified persons after each assessment, and that services provided or arranged by the manor will meet professional standards of quality. Review of Resident R2's clinical record revealed an admitted [DATE], with diagnoses that included left-sided weakness related to stroke, obesity, depression, anxiety, high blood pressure, and Type 2 Diabetes (condition that affects how the body uses glucose [sugar]). The clinical record also revealed a care plan entitled, potential to demonstrate physical/verbal behaviors related to anger dated 10/21/19. The care plan had not been updated with new interventions since 9/14/20, and a care plan entitled, depression and dated 2/24/21, indicated that it had not been updated with new interventions since 4/06/22. Review of Resident R2's Behavior Monitoring and Intervention Report from 9/01/23, to 9/21/23 (20 days), revealed nine incidents of displaying targeted behaviors and the attempted interventions were ineffective (9/03/23, 9/13/23 twice, 9/14/23, 9/15/23, 9/16/23, 9/17/23, 9/19/23, and 9/20/23). Review of facility documents provided on 9/21/23, from the Behavior Committee Meeting Minutes revealed: that on 5/11/23, Resident R2 exhibited behaviors 34 times in a 14-day lookback and the recommendation was to respond timely, communicate and educate; on 7/18/23, Resident R2 exhibited behaviors 52 times in a 30-day lookback and the recommendation was to have night staff get music and football on his/her TV. Review of contracted psychological staff evaluation of Resident R2 dated 5/20/23, revealed that Resident R2 had reported significant symptoms related to depression, and to follow-up in one month or sooner if needed. There was no evidence that Resident R2 was evaluated as per the evaluation. During an interview on 9/22/23, at 11:55 a.m. the Regional Clinical Specialist confirmed that Resident R2's behavior and depression care plans were not updated when interventions were not effective. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations and staff interview, it was determined that the facility failed to display the Department of Health (DOH) Hotline (toll-free telephone number) number in a prominent/accessible location for residents, resident representatives, and other visitors to observe and access in the facility. Findings include: Observations throughout the facility between 9/19/23, and 9/22/23, revealed that the DOH Hotline phone number was not posted for residents, resident representatives, and other visitors. During an interview on 9/22/23, at 10:20 a.m. the Regional Clinical Specialist confirmed the facility failed to display the DOH Hotline phone number for residents, resident representatives, and other visitors. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e) (2.1) Management

Based on review of clinical record and staff interview, it was determined that the facility failed to ensure medications were administered according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of Resident R17's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the September 2022, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the October 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] There was no documentation that the physician was notified of a need to hold or alter the time of administration for the Calcium Acetate and [MEDICATION(S)] for Resident R17 on [CONDITION(S)] days. During an interview on 10/20/22, at 2:00 p.m. the Director of Nursing confirmed that the above medications for Resident R17 were not administered on [CONDITION(S)] days as ordered by the physician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to appropriately label over-the-counter stock (multi-dose containers of medications utilized for more than one resident) medications on two of three medication carts (A-Hall and C-Hall). Findings include: Review of facility policy dated 12/1/21, entitled House Supply Drugs revealed that It is the responsibility of the nursing staff to properly label each house supplied medication on the unit. and that Each Resident that has a current order for a house supplied medication must have his or her first and last name appear on a bottle . and that No more than ten residents may share one bottle of a house suppled medication. During observation of medication administration on A-Hall on 10/18/22, between 3:30 p.m. and 3:50 p.m., it was noted that Registered Nurse (RN) Employee E1 utilized a house supplied bottle of [NAME]-Bid Probiotic for Resident R11. Inspection of the bottle revealed that there was only the first name of one resident written one bottle. During an interview at the time of observation, RN Employee E1 stated whoever opens the bottle the first time it is used, puts that resident's name on it and that is all. During observation of medication administration on C-Hall on 10/18/22, between 3:55 p.m. and 4:07 p.m. it was noted that Licensed Practical Nurse (LPN) Employee E2 utilized a house supplied bottle of [NAME]-Bid Probiotic, Tylenol 325 milligrams, and [MEDICATION(S)] 200-200-20 milligrams per 15 milliliters for Resident R42. Inspection of all three bottles revealed there were no resident names listed. During an interview at the time of observation, LPN Employee E2 stated whoever opens the new bottle tries to remember to put the residents name on it, but that when you're in the middle of a med pass that is not always possible. During an interview on 10/19/22, at approximately 11:00 a.m. the Director of Nursing confirmed that house supplied medications are to contain the first and last name of reach resident utilizing that bottle. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.9(a)1) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that potential safety hazards were secured in kitchen cupboards and drawers and not present in resident rooms for one of four units (dementia unit) and one of 22 residents reviewed (Resident R41). Findings include: Observations on 11/16/21, at 2:45 p.m. in the dementia unit's multi-purpose room where residents sit and wait for their meals, eat their meals, play games, color pictures, sit and relax, etc. revealed that two kitchen cupboards and one kitchen drawer were not locked. The two kitchen cupboards contained the following: Super HDQ Neutral Disinfectant (highly concentrated broad spectrum disinfectant) Fan Glass candle and glass jar Three curling irons Hair spray Fingernail polish The one kitchen drawer contained the following: Pencil sharper Television remote Garbage bags During an interview on 11/16/21, at 2:48 p.m., Nurse Aide Employee E3 verified the contents of the cupboards and drawer. During an interview on 11/18/21, at 4:25 p.m., the Nursing Home Administrator confirmed that the kitchen cupboards and drawers should be locked at all times in the dementia unit. Review of Resident R41's clinical record revealed that he/she was admitted on [DATE], with diagnoses that included Alzheimer's disease (brain disorder that that slowly destroys memory and thinking), chronic obstructive pulmonary disease (condition that causes airflow blockage and breathing-related problems), and dementia (group of thinking and social symptoms that interferes with daily functioning). Review of Resident R41's behavioral care plan focus created on 9/8/14, identified I have diagnosis of [CONDITION(S)] disorder, [CONDITION(S)], depression and anxiety. I can be resistant to care and sometimes have behaviors daily. I yell at others and sometimes yell at my own reflection. I have [CONDITION(S)] r/t my behaviors. I have a history of pulling apart my incontinence products and eat the cotton padding. I become combative with care, I will hit, kick, grab and pinch. I have a history of smearing feces on myself and on objects in my room. I have a history of climbing out of bed and climbing around on the floor and usually I have no clothes on while doing this. Observation on 11/16/21, at 3:00 p.m. in Resident R41's room revealed that there was a bottle of peri cleanser (skin cleanser designed to clean urine, emesis, and fecal matter) that was opened with the lid lying next to the bottle on the nightstand. During an interview at the time of the observation, Licensed Practical Nurse Employee E1 confirmed that the bottle of peri cleanser should not be left in Resident R41's room. During an interview on 11/18/21 at 4:27 p.m. the Director of Nursing confirmed that there should not be a bottle of peri cleanser left in Resident R41's room. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records, facility policies and staff interviews, it was determined that the facility failed to follow professional standards of practice and provide necessary care and services by not informing the physician of a significant change in condition for one of eight residents reviewed (Closed Record Resident (CR1) that resulted in actual harm to Resident CR1 who encountered a hospitalization for a complicated urinary tract infection. This deficiency is cited as past non-compliance (Resident CR1). Findings include: The Notification of policy dated 12/12/18, indicated that the facility must inform the resident immediately, the attending physician and the resident's representative or interested family member when a significant change in the resident's physical mental or psychosocial status occurs. The Catheter Care policy, dated 12/12/18, indicated to report any abnormalities to the nurse such as: redness, drainage, odor, swelling, discoloration, etc. The Catheter Closed Urinary Drainage policy dated 12/12/18, revealed that any unusual symptoms such as pain, bleeding, lack of flow, etc. was to be documented in the nursing notes and on the 24 hour report, to notify the physician immediately in the event of hemorrhage or incidents such as the catheter was pulled out. The admission record revealed that Resident CR1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-a periodic review of resident care needs), dated 4/23/19, revealed that Resident CR1 was admitted with a catheter (tubing inserted into the bladder to drain urine). The nurses notes revealed that Resident CR1 had a new physican order written [REDACTED]. The catheter was not changed until 6/13/19, at 3:45 a.m. per the Treatment Administration Record (TAR). There was no documentation to indicate how the resident tolerated the procedure or the reason the change occurred at 3:45 a.m. At 7:00 a.m. on 6/13/19, Licensed Practical Nurse (LPN) Employee E2 documented that Resident CR1's foley catheter intact and patent draining large amount of deep red colored hematuria (blood). Sediment and some clotting present in the tubing and catheter bag. Resident was complaining of some suprapubic (low abdomen) tenderness. There was no documentation to indicate that the RN or the physician were notified of this change in the Resident CR1's condition. At 2:42 p.m. on 6/13/19, LPN Employee E2 documented Resident CR1's penis was observed to be swollen with some difficulty retracting the foreskin. The resident complained of some tenderness to the area. There was no evidence that the RN and physician were notified of the issues. At 11:12 p.m. on 6/13/19, LPN Employee E3 documented the foley patent, draining without difficulty, hematuria observed, resident complaining it hurts when I pee. Meatus (opening at the head of the penis) swollen, unable to pull foreskin (skin that folds over the head of the penis) back over. At 11:34 p.m. on 6/13/19, RN Employee E4 documented called down to resident's room due to resident complaining of pain while urinating. Foley intact, with 350 cubic centimeters of pink tinged clear yellow urine in the bag, attempted to reposition the catheter by emptying the balloon which caused a large clot to expel from the head of penis, blood continued to leak from the head of the penis not the foley, appears to be coming from shaft of penis, balloon reinflated placed on the MD board for advisement. There was no evidence produced by the facility of evidence of the information placed on the MD board nor the physician notified of the residents change in condition. The Medication Administration Record [REDACTED].m on 6/13/19, for penis pain. At 7:00 a.m. on 6/14/19, LPN Employee E5 documented foley catheter is patent and draining clear yellow urine and no pain. There was no observation of the penis or if the swelling had subsided or that any blood was coming from the meatus. At 11:07 p.m. on 6/14/19, LPN Employee E6 documented foley catheter patent and draining dark yellow urine. On 6/15/19, at 3:06 a.m. LPN Employee E6 documented the foley was patent draining dark tea colored urine with mucous shreds. There was no documentation to indicate that the physician was notified of the changing urine color/condition. On 6/15/19, at 7:00 a.m. LPN Employee E5 documented foley catheter is patent and draining bloody urine. There was no evidence that the physician was notified of the change in the urine color. On 6/15/19, at 1:55 p.m. RN Employee E8 documented that the physician was made aware of a bruise to the residents left elbow. There was no documentation that the physician was made aware of the change in the resident's condition regarding the discolored urine/pain/fever/swelling. Review of the vital sheet with recorded temperatures noted that Resident CR1 had elevated temperatures recorded between 6/15/19, at 3:30 p.m with a temperature of 100.7 degrees Farenheit (F) until 6/16/19, with a final rectal temperature of 100.9 F at 2:30 p.m. and had been medicated with Tylenol at least five times during that time period for fever. On 6/16/19, at 7:00 a.m. LPN Employee E5 documented that the foley was draining red urine. On 6/16/19, at 1:09 p.m. RN Employee E8 notified the MD of the increased temperatures and the hematuria and got an order for [REDACTED].>At 3:00 p.m., LPN Employee E5 documented that the family requested Resident CR1 to go to the emergency room for treatment. During an interview on 8/13/19, at 1:20 p.m. the Director of Nursing (DON) confirmed that the physician should have been notified of Resident CR1's change in condition on 6/13/19, when the issues developed with the penis and the change in urine. During an interview on 8/14/19, at 11:54 a.m. RN Employee E8 confirmed that the physician was not made aware of the discolored urine or issues that Resident CR1 was having concerning the catheter when the physician was notified of the bruise on 6/15/19, at 1:55 p.m. This deficiency is cited as past non-compliance. On 7/23/19, the facility initiated a plan of correction to address the substantiated concern of not notifying the physician regarding the continued change in condition of Resident CR1 that included the following: 1) a three week review of progress notes for current catheterized residents was completed to ensure any change in condition was appropriately notified; 2) catheter care competencies were completed on all RNs, LPNs, and STNAs; 3) infection control nurse completed an audit of all residents with catheters; 4) catheter insertion and irrigation competencies on all RNs and LPNs; 5) nurses have been educated on the interact notification tool on when to notify physicians; 6) nurses have been educated and have implemented the change in condition form; 7) a change in condition policy and procedure has been initiated; 8) nurses have been educated on Point Click Care documentation requirements and when to use change in condition progress notes; 9) nurses have been educated on notification of changes policy; 10) the Clinical Stand Up/Stand Down form has been initiated to ensure daily follow up; 11) a charge nurse reference binder has been created to ensure instructional consistency; 12) the DON audits the change in condition form for compliance daily; 13) results of all audits will be reviewed through the Quality Assurance Performance Improvement process. Documentation provided by the facility during an interview on 8/13/19, at 12:45 p.m. with the Nursing Home Administrator and DON confirmed that the facility had achieved compliance with care and services and notification at this time and will continue to monitor on a random basis. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services