Every finding on record at Brethren Village

Based upon clinical record review and staff interview, it was determined that the facility failed to ensure non-pharmacological interventions were completed prior to the administration of as needed anti-anxiety medication for one of five residents reviewed (Resident 51).Findings include:Review of Resident 51's physician's orders revealed an order for Ativan (anti-anxiety medication) 0.5 milligrams (mg) to be administered every four hours as needed for anxiety/restlessness.Review of Resident 51's January Medication Administration Record (MAR) revealed Resident 51 received Ativan 0.5 mg on January 1, January 2, January 3, January 5, January 6, January 8, January 9, January 10, January 11, January 21, January 22, January 26 and January 27, 2026.Review of Resident 51's clinical record failed to reveal evidence that non-pharmacological interventions were attempted prior to the administration of as needed Ativan on the above-mentioned dates.Interview with the Nursing Home Administrator and Director of Nursing on January 30, 2026, at 10:50 a.m. confirmed that no non-pharmacological interventions were attempted prior to the administration of the as needed Ativan. 28 Pa. Code 211.12(c)(d)(1)(2)(5) Nursing Services

Based upon review of facility policy and procedure, clinical record review and staff interview, it was determined that the facility failed to ensure physician's orders were followed for administration of as needed pain medication for one of five residents reviewed (Resident 51.)Findings include:Review of facility policy and procedure titled Pain Observation/Evaluation revised January 2026 revealed Pain will be measured using the following pain scales: 1) 0-10 scale - this is a subjective scale where the patient communicates the current level of pain. Zero equals no pain and 10 equals the most severe pain. 2) Mild pain identified at times 0-3; moderate 4-7; severe pain 8-10 on scale.Review of Resident 51's January 2026 physician orders revealed an order for Oxycodone (narcotic pain medication) 5 milligrams (mg) administer one tablet every 6 hours as needed for severe pain.Review of Resident 51's January Medication Administration Record (MAR) revealed Resident 51 received Oxycodone 5 mg every 6 hours as needed for pain levels of zero on January 2, January 3, January 9, January 20, January 21, January 22, January 26 and January 30, 2026.Interview with the Nursing Home Administrator and Director of Nursing on January 30, 2026, at 10:50 a.m. confirmed that the pain scale utilized in the physician's order for as needed pain medication was not followed according to physician orders. 28 Pa. Code 211.12(c)(d)(1)(2)(5) Nursing Services

Based on review of facility policy and procedure, clinical record, facility documentation, and staff interviews, it was determined the facility failed to ensure that one of three residents reviewed were free from neglect during care resulting in actual harm causing a subcapital humeral fracture for Resident 1. Findings include: Review of facility policy titled Freedom from Abuse, Neglect, and Exploitation, last revised October 2024, revealed neglect is the failure of the facility, its Team Members or service providers to provide care, goods, or services to a Resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Resident 1's diagnosis sheet revealed diagnoses of Hemiplegia and Hemiparesis (weakness and paralysis) following Cerebral Infarction (stroke) affecting dominate side, severe protein-calorie malnutrition, history of falling, and contractures of the right elbow and hand. Review of Resident 1's care plan revealed a care plan for limited physical mobility related to Cerebrovascular Accident (stroke) with right sided weakness, including an intervention for Extensive two (person) assist for transfers, initiated January 25, 2025. Review of Resident 1's Care Kardex under Bed Mobility revealed Resident 1 was to have 2 person assist for transfers. Review of Resident 1's Quarterly Minimum Data Set (MDS-periodic assessment of resident needs), dated July 1, 2025, revealed Resident 1 required assistance from staff while transferring and had weakness on one side of their body. Review of Resident 1's progress notes revealed a Nursing Note on July 30, 2025, at 5:16 p.m. indicating Resident reported to a CNA (certified nurse aide) on 3-11 shift that [he/she] felt a pop in [his/her] right shoulder after being helped by one CNA today. Resident is a 2A (two person assist). [Resident] complained of pain in [his/her] right shoulder and tenderness as noted when moving RUE (right upper extremity) . Order obtained from provider for STAT (immediate) Xray of the right shoulder and Humerus (long bone of the upper arm) to r/o (rule out) and fracture or dislocation. Review of information submitted by the facility on July 30, 2025, to the Department of Health revealed, RN Supervisor immediately went to assess resident. Scheduled Tylenol administered by charge nurse and effective. Interview completed by nursing staff and social worker. Order obtained from provider for STAT Xray of the right shoulder and humerus Investigation is completed. (AP-alleged perpetrator) was an agency CNA who confessed to giving the resident a bear hug. Agency aware and CNA DNR'd (Do Not Return). Review of Resident 1's x-ray report, dated July 30, 2025, revealed a subcapital (part of the bone closest to the shoulder) humeral fracture. Review of facility investigation into the injury revealed a witness statement from licensed nursing employee E3 interviewing Resident 1 on July 30, 2025, indicating Resident 1 said, when she (staff member) went to lift me over she was standing next to the wheelchair and I was by the recliner and she said ‘oh', and all of a sudden I heard a pop. You couldn't miss it. It was loud. She said, ‘I'm sorry' and kept asking ‘Do you feel better? Is it ok now?' And I said, ‘not right now I don't.' then she was ready to leave and gathered her things. Further review of facility investigation into incident revealed an interview of nursing employee E4 by licensed nursing employee E5 on August 1, 2025, at 11:20 a.m. indicated, I asked her exactly what happened. She stated, ‘I bear hugged [resident] and transferred [resident] alone.' ‘I am so sorry [resident] got hurt.' ‘She didn't tell me she hurt [resident]. Further review of the facility investigation of the injury revealed the facility substantiated the allegation of neglect for not following the care plan for the resident to have the assistance of two staff members while transferring the resident. Interview with the Nursing Home Administrator and the Director of Nursing on August 26, 2025, at 1:30 p.m. confirmed Resident 1 was not transferred according to resident's individual care plan causing actual harm to Resident 1 when Resident 1 sustained a fractured humerus as a result of the improper transfer. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, hospital records, and staff interviews, it was determined the facility failed to provide necessary services of consistent wound treatment and ensure correct wound medication was applied to an unstageable wound (obscured full-thickness skin and tissue loss). The failure caused actual harm to Resident CL1 when the wound deteriorated and become infected resulting in hospitalization and unnecessary pain for one of three residents reviewed. (Resident CL1) Findings include: Review of the facility's policy titled Freedom from Abuse, Neglect, and Exploitation last revised in [DATE], revealed, facility is committed to interacting with and treating its Residents with dignity and respect. While a resident at or in the care of the facility, each resident is to be free from Abuse, exploitation, fraud, misappropriation of property, harassment, neglect, and mistreatment. Neglect is defined as the failure of the facility, its Team Members, or service providers to provide care, goods, or services to a Resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Resident CL1's diagnosis list includes thoracic spinal cord injury, and Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period). Review of Resident CL1's Admission Braden Scale (scale used for predicting pressure sore risk) completed on [DATE], revealed resident was At Risk for developing pressure ulcers. Review of Resident CL1's admission skin assessment revealed Resident CL1 was admitted to the facility on [DATE], with an improving Stage 3 Pressure Ulcer (full thickness skin loss) to the coccyx (commonly known as the tail bone is a small triangular bone located at the bottom of the spine) with a measurement of 1.2 x 1.0 x 0 cm (centimeter). Review of Resident CL1's physician order dated [DATE], revealed a new wound treatment to cleanse the coccyx/sacrum with normal saline and apply Medihoney (dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns) and Calcium Alginate (wound dressing used to absorb wound exudate) then cover with dressing daily in the evening and as needed. Review of Resident CL1's [DATE], Treatment Administration Record (TAR) and progress notes failed to reveal documented evidence of Resident CL1's unstageable coccyx wound was treated on [DATE], [DATE], and [DATE]. Interview conducted with Licensed Nursing Employee E4 on February 5, 2025, at 1:30 p.m., revealed the daily Medihoney wound treatment order expired on [DATE], and was not renewed by nursing. The as needed treatment order remained and was administered on [DATE]. Further interview with licensed nursing Employee E4 confirmed the daily wound treatment order should have been renewed on [DATE]. Review of Resident CL1's clinical record failed to reveal documentation of the attending physician being notified of the missed wound care treatments on [DATE], [DATE], and [DATE]. Review of Resident CL1's Wound and Skin Evaluation dated [DATE], at 7:22 a.m., revealed Resident CL1's coccyx wound was deeper with new slough (layer of dead, yellow or white tissue that covers the wound bed) areas distal to the opening. The wound was identified as unstageable pressure ulcer with measurement of 1.0 x 4.3 x 2.5 cm. with 100% slough. A new treatment of Santyl (topical medication used for removing damaged or burned skin to allow for wound healing and growth of healthy skin) was recommended. Review of Resident CL1 physician's order dated [DATE], revealed a wound care order to cleanse the coccyx/sacral wound with normal saline, apply a Santyl pack with Calcium Alginate then cover it with a foam dressing daily. Interview with the Nursing Home Administrator (NHA) on February 5, 2025, at 1:00 p.m. revealed when the wound nurse assessed the resident's coccyx wound on [DATE], he/she discovered that the Santyl medication was not available but the Treatment Administration Record was documented as treatment was administered. Facility investigation revealed the Santyl medication was incorrectly entered in the computer which resulted in the medication not being delivered. The Santyl medication was re-ordered. Interview with licensed nurse Employee E3 on February 5, 2025, at 2:00 p.m. revealed on [DATE], Resident CL1's Santyl medication was not available in the facility, the nurse stated the wound was instead cleansed with normal saline and was lightly packed with Calcium Alginate then covered with a foam dressing. Employee E3 reported the same treatment without the santyl was done on [DATE], and [DATE]; since the Santyl medication was still not available. Employee E3 reported she/he assumed the medication would be delivered soon and did not call the pharmacy to follow up on the medication, did not inform the supervisor that medication was not available, and did not inform the physician that the medication was not available and therefore treatment order was not done as ordered on [DATE], [DATE], and [DATE]. Review of Resident R1's nursing progress notes dated [DATE], at 2:00 p.m., revealed the wound dressing was replaced due to soilage, awaiting delivery of Santyl from the pharmacy, the order was re-entered in the computer. Review of the pharmacy delivery records revealed Resident CL1's Santyl medication wasn't delivered to the facility until [DATE], four days after it was ordered by the physician. Review of Resident CL1's Wound and Skin Evaluation, dated [DATE] 8:18 a.m., revealed Resident CL1's coccyx wound was determined unstageable with a measurement of 4.9 x 4.4 x 2.5 cm. with 4.0 cm tunneling (wound that progressed to form passageways underneath the surface of the skin) at 6 o'clock, 100% slough with increased moderate purulent (product of inflammation that contains pus (e.g., leukocytes, bacteria, and liquefied necrotic debris), and moderate odor. Further review of same document revealed a wound culture was ordered and collected due to purulent discharge and odor in the area and resident's body temperature of 102 F (farenheit) recorded the previous evening. Resident CL1's current temperature was 99.9 F (normal body temperature range for adults is 97.0 - 99.0 F). Review of the wound culture report dated February 1, 2025, revealed Resident CL1's coccyx wound was positive for the following organisms: Staphylococcus Aureus, Enterococcus Avium, Enterococcus Faecalis, and Morganella Morganii. Review of CL1's clinical records revealed Resident CL1's wound treatment was changed, antibiotic treatment was started, and Resident CL1 was scheduled to be seen by a wound specialist. Review of the wound consult dated February 3, 2025, revealed the Patient (Resident CL1) with a Stage 4 Pressure Ulcer (Full-thickness skin and tissue loss) of sacrum, diffuse necrotic tissue (The death of the cells in the body tissue) in the base. Skin exam revealed Stage 4 sacral ulcer with necrotic tissue, foul odor, (+) rough exposed bone. The same report revealed that the physician attempted to do debridement (Removal of dead, infected, or damaged tissue from a wound), but the patient was sensate unable to accomplish much. The physician recommended operative debridement in the Operating Room and Intravenous (IV) (medication administered in vein) antibiotics. Review of Resident CL1's clinical record revealed Resident CL1 was sent to the hospital on February 4, 2025. Review of the hospital record document titled History and Physical, dated February 5, 2025, revealed patient (Resident CL1) was seen in the wound clinic by surgery [physician's name] and tried to debride the diffuse necrotic base, but the patient did not tolerate it due to pain. Admission was requested for debridement under general anesthesia. The resident was placed on IV antibiotics and was referred to surgery for wound debridement. Review of information dated [DATE] submitted by the facility, on Janaury 29, 2025 revealed the faciltiy substantiated neglect for Employee E3 and Employee was reeducated. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on February 6, 2025, at 2:30 p.m. The facility failed to provide wound treatment to Resident CL1's unstageable coccyx consistently and failed to ensure the correct wound treatment was administered. This failure resulted in actual harm to Resident CL1 causing the wound to deteriorate, become infected, leading to hospitalization where added surgical procedures added unnecessary pain. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE] 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited [DATE] 28 Pa. Code 201.18(e)(3) Management Previously cited [DATE] 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited [DATE]

Based facility policy review, clinical record review, hospital record review, facility documentation review, and staff interviews, it was determined that the facility failed to provide consistent and appropriate treatment for an Unstageable Pressure Ulcer (obscured full-thickness skin and tissue loss), resulting in wound deterioration, infection, and hospitalization for one of three residents reviewed (Resident CL1). Findings include. Review of the facility's policy titled Skin Care/Integrity, last revised in February 2024, revealed that the facility's policy is to identify residents at risk for impairment in skin integrity, initiate appropriate preventative interventions, and provide treatment to promote healing, prevent infections, and prevent the development of pressure ulcers. Review of the facility's policy titled Pressure Wounds, last reviewed in May 2024, revealed wounds in the category of pressure will have an appropriate treatment to promote the healing process. Review of Resident CL1's diagnosis list includes thoracic spinal cord injury, neuromuscular dysfunction of bladder, and Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period). Review of Resident CL1's admission skin assessment revealed Resident CL1 was admitted to the facility on [DATE], with an improving Stage 3 Pressure Ulcer (Full thickness skin loss) measuring 1.2 x 1.0 cm to the coccyx (commonly known as the tail bone, is a small triangular bone located at the bottom of the spine). A wound treatment order was in place. Review of Resident CL1's Admission Braden Scale (scale used for predicting pressure sore risk) completed on December 28, 2024, revealed resident was At Risk for developing pressure ulcers. Review of Resident CL1's care plan revealed that the skin impairment care plan was developed on December 28, 2024, with interventions as follows: chair cushion; adequate nutrition; resident education; turning and positioning; incontinent care and to provide wound treatment as ordered. Review of the physician's order dated January 3, 2025, revealed a wound treatment to cleanse the coccyx/sacrum with normal saline and apply Medihoney (dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns) and Calcium Alginate (wound dressing used to absorb wound exudate) then cover with dressing daily in the evening and as needed. Review of the Wound and Skin Evaluation dated January 16, 2025, at 7:39 a.m., revealed Resident CL1's coccyx wound was unstageable with a measurement of 2.0 x 1.2 x 1.5 cm. with 80% slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) with moderate serous drainage (watery, clear, or slightly yellow/tan/pink fluid that has separated from the blood and presents as drainage) with no signs of infection. Wound treatment remained Medihoney and Calcium Alginate. Review of Resident R1's January 2025, Treatment Administration Record (TAR) and progress notes failed to reveal documented evidence that Resident CL1's unstageable coccyx wound was treated on January 20, January 22, and January 23, 2025. Review of Resident R1's clinical records failed to reveal the attending physician was notified of the missed wound care treatments on January 20, January 22, and January 23, 2025. Interview conducted with Licensed Nursing Employee E4 on February 5, 2025, at 1:30 p.m., confirmed there were no documented evidence of the physcian being notified of the missed wound treatments. Review of the Wound and Skin Evaluation dated January 23, 2025, at 7:22 a.m., revealed Resident CL1's coccyx wound was unstageable with a measurement of 1.0 x 4.3 x 2.5 with 100% slough and moderate serous drainage with no evidence of infection. The same note revealed deteriorating, the area was deeper with new slough areas distal to the opening. A new treatment of Santyl (topical medication used for removing damaged or burned skin to allow for wound healing and growth of healthy skin) was recommended. Review of Resident R1's physician's order dated January 23, 2025, revealed a wound care order to cleanse the Coccyx/sacral wound with normal saline apply a Santyl pack with Calcium Alginate then cover it with a foam dressing daily. Review of the pharmacy delivery records revealed that Resident CL1's Santyl medication was not delivered to the facility until January 27, 2025, four days after it was ordered by the physician. Interview with licensed nurse Employee E3 was conducted on February 5, 2025, at 2:00 p.m. Employee E3 reported that on January 24, 2025, Resident CL1's Santyl medication was not available, the nurse stated the wound was instead cleansed with normal saline and was lightly packed with a Calcium Alginate then covered with foam dressing. Employee E3 reported the same treatment was done on January 25, and January 26, 2025, since Santyl medication was still not available. Employee E3 reported that she/he assumed the medication would be delivered soon. Employee E3 reported she/he did not call the pharmacy to follow up on the medication, did not inform the supervisor the medication was not available, and did not inform the physician the treatment order was not appropriately done. Review of the Wound and Skin Evaluation, dated January 28, 2025, at 8:18 a.m., revealed Resident CL1's coccyx wound was unstageable with a measurement of 4.9 x 4.4 x 2.5 cm. with 4.0 cm tunneling (wound that progressed to form passageways underneath the surface of the skin) at 6 o'clock, 100% slough with increased moderate purulent (Is any product of inflammation that contains pus (e.g., leukocytes, bacteria, and liquefied necrotic debris), and moderate odor. Additional review of the same note revealed, a wound culture was ordered and collected due to purulent discharge and odor in the area and a temperature of 102 F the night before. The current temperature was 99.9 F (normal body temperature range for adults is 97.0 - 99.0 F). Review of the wound culture report dated February 1, 2025, revealed Resident CL1's coccyx wound was positive for the following organisms: Staphylococcus Aureus, Enterococcus Avium, Enterococcus Faecalis, and Morganella Morganii. Review of Resident CL1's clinical records revealed wound treatment was changed to continuous negative pressure wound vacuum at 125 mm Hg on January 29, 2025. The resident was placed on antibiotics and was scheduled for a wound clinic consult. Review of the wound consult dated February 3, 2025, revealed the patient had a Stage 4 Pressure Ulcer (Full-thickness skin and tissue loss) of sacrum, diffuse necrotic tissue (death of the cells in the body tissue) in the base. Skin exam revealed Stage 4 sacral ulcer with necrotic tissue, foul odor, (+) rough exposed bone. The same report revealed that the physician attempted to do debridement (Removal of dead, infected, or damaged tissue from a wound), but the patient was sensate unable to accomplish much. Pre procedure wound area was 48.24 cm2 (square centimeter), post debridement measurements were 6.7 x 7.2 x 5.6 cm with 76-100% slough and 1-25% eschar. The physician recommended operative debridement in the Operating Room and Intravenous (IV) (medication administered in vein) antibiotics. Review of Resident CL1's clinical records revealed Resident was sent to the hospital on February 4, 2025. Review of the hospital record History and Physical, dated February 5, 2025, revealed patient was seen in the wound clinic by surgery [physician's name] and tried to debride the diffuse necrotic base, but the patient did not tolerate it due to pain. Admission (hospital) was requested for debridement under general anesthesia. The same note revealed that the diagnosis of admission was Pressure Injury of the sacral region, stage 4. The patient was placed on IV antibiotics and was referred to surgery for debridement. The above information was discussed with the Nursing Home Administrator and the Director of Nursing on February 5, 2025, at 2:30 p.m. The facility failed to ensure Resident CL1 was provided with consistent and appropriate wound treatment on her/his sacral wound which resulted in actual harm when the wound deteriorated and became infected causing hospitalization and a surgical procedure that led to unnecessary pain. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 4/6/23 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 4/6/23 28 Pa. Code 201.18(e)(3) Management Previously cited 4/6/23 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 4/6/23

Based on review of the Pennsylvania Professional Nursing Practice Act, facility policy and procedure review, clinical records review and staff interviews it was determined the facility failed to ensure that staff met the professional standards for a licensed nurse in following a physician's wound care order for one of three residents reviewed (Resident CL1). Finding Include: The Professional Code, Title 49, Professional and Vocational Standards (Pennsylvania Professional Nursing Practice Act), Chapter 21.145(a) states that the Licensed Practical Nurse (LPN) is prepared to function as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, and experience in nursing competency. The LPN participates in the planning, implementation, and evaluation of nursing care, using focused assessment in settings where nursing takes place. Chapter 21.145 (3) states, an LPN shall follow the written, established policies and procedures of the facility that are consistent with the Act. A review of the facility's policy titled Skin Care/Integrity, last revised in February 2024, revealed that the facility's policy is to identify residents at risk for impairment in skin integrity, initiate appropriate preventative interventions, and provide treatment to promote healing, prevent infections, and prevent the development of pressure ulcers. A review of the facility's policy titled Pressure Wounds, last reviewed in May 2024, revealed that wounds in the category of pressure will have an appropriate treatment to promote the healing process. A review of the physician's order dated January 3, 2025, revealed a wound treatment to cleanse the coccyx/sacrum with normal saline and apply Medihoney (A dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns) and Calcium Alginate (A wound dressing used to absorb wound exudate) then cover with dressing daily in the evening and as needed. A review of the January 2025, Treatment Administration Record (TAR) and progress notes revealed no documented evidence that Resident CL1's unstageable (Obscured full-thickness skin and tissue loss) coccyx (commonly known as the tail bone is a small triangular bone located at the bottom of the spine) wound was treated on January 20, 22, and 23, 2025. Clinical records review failed to reveal that the physician was notified of the missed wound care treatment on January 20, 22, and 23, 2025. A review of the physician's order dated January 23, 2025, revealed a wound care order to cleanse the Coccyx/sacral wound with normal saline apply a Santyl pack with Calcium Alginate then cover it with a foam dressing daily. A review of the pharmacy delivery records revealed that Resident CL1's Santyl medication was not delivered to the facility until January 27, 2025, four days after it was ordered by the physician. An interview with licensed nurse Employee E3 was conducted on February 5, 2025, at 2:00 p.m. Employee E3 reported that on January 24, 2025, Resident CL1's Santyl medication was not available, the nurse reported that the wound was instead cleansed with normal saline and was lightly packed with a Calcium Alginate then covered with foam dressing. Employee E3 reported that the same treatment was done on January 24, and 25, 2025, since Santyl medication was still not available. Employee E3 reported that she/he assumed that the medication would be delivered soon. Employee E3 reported that she/he did not call the pharmacy to follow up on the medication, did not inform the supervisor that medication was not available, and did not inform the physician that the wound treatment order was not followed for three days. The above was conveyed with the Nursing Home Administrator and Director of Nursing on February 5, 2025, at 2:00 p.m. The facility failed to ensure that the staff met the professional standard on providing appropriate and ordered treatment to Resident CL1's coccyx wound. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 4/6/23. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 4/6/23. 28 Pa. Code 201.18(e)(3) Management Previously cited 4/6/23. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 4/6/23. 28 Pa. 211.10(c) Resident care policies

Based on clinical records, facility documentation review, and resident and staff interview, it was determined that the facility failed to ensure that the resident was free from neglect by not providing two-person assistance needed during transfers or providing the proper equipment during a transport for two of 32 residents reviewed (Residents 14 and 91) causing actual harm to Resident 14. Findings Include: Review of Resident 14's diagnosis list included a diagnosis of intracranial hemorrhage (stroke) and Hemiplegia non-dominate left side (inability to move one side of the body). Review of Resident 14's care kardex revealed as of January 30, 2023 Resident 14 was to have the foot pedals of the wheelchair removed while in the room as resident prefers to self-propel independently when in room. Utilize wheelchair foot pedals when assisting resident with mobility in the hallway. Review of Resident 14's care plan revealed interventions to prevent falls including an intervention initiated October 11, 2021, to encourage foot pedals when assisting resident with wheelchair mobility in the hallway. Review of Resident 14's progress notes revealed a nursing entry dated January 30, 2023, at 2:05 p.m. revealed CNA (Certified Nursing Assistant) pushing resident in WC (wheelchair) to dining room. Resident left foot caught on floor causing resident to fall forward, land on floor face down. Resident able to roll on left side to a seated position, resident assisted to WC by three employees, Pressure held to nose d/t (due to) bleed. Further review of Resident 14's progress notes revealed Resident 14 was having nose bleeds but not reporting any pain or discomfort in his/her face. Additional review of Resident 14's clinical record revealed a progress note dated February 6, 2023, at 4:26 p.m. indicating family is requesting [Resident 14] be sent to the ER (emergency room ) for epistaxis (nosebleed). Review of documentation from the hospital stay of February 6-7, 2023, revealed the resident was admitted with diagnosis of epistaxis due to trauma, closed bilateral (both sides) nasal bone fractures, concussion, fall from wheelchair, acute blood loss anemia (low blood cell count) and coagulopathy (inability of blood to clot). Interview with Resident 14 on March 29, 2023, at 1:00 p.m. confirmed when she had the fall on January 30, 2023, she did not have the foot pedals on the wheelchair at the time of the fall. Resident 14 stated she was not asked if she wanted them or not and didn't want to say anything because she thought the CNA was busy at the time. Resident 14 confirmed that the foot pedals have been used every time when transferred outside of her room since her fall. Interview with the Director of Nursing on March 29, 2023, at 11:00 a.m. revealed Nursing Employee E4 resigned from her position and no longer worked at the facility after January 30, 2023. Interview with the Nursing Home Administrator on March 30, 2023, at 9:30 a.m. confirmed Resident 14's foot pedals were not placed on the wheelchair as both the care plan and care kardex instructed when transferring Resident 14 in the hallway. Review of documention provided by the facility revealed facility substantiated the allegation of neglect against the nurse aide who failed to follow care kardex and care plan by not providing foot pedals to wheelchair during transport. Resident 14 sustained a fall due to the facility staff not following Resident 14's care plan and care kardex interventions of placing foot pedals on the wheelchair while transporting the resident in the hallway causing actual harm when Resident 14 was transferred to the hospital and diagnosed with facial fractures. Review of facility audits of foot pedal placement and education provided to all nursing staff revealed the education provided was regarding wheelchair and use of foot pedals but did not address ensuring safety during transfers. Review of Resident 91's diagnosis list revealed Parkinson's Disease (disorder of the central nervous system that affects movement, often including tremors), a history of falls, and a left femur (thigh bone) fracture. Review of Resident 91's Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated January 7, 2023, revealed that the resident had severe cognitive impairment. The MDS also revealed that the resident requires extensive two-people assistance with transferring. Review of Resident 91's current care plan for safety revealed an intervention initiated on July 12, 2022, for two-person assistance with transferring with a rolling walker. Review of Resident 91's nursing progress notes dated February 26, 2023, at 2:09 a.m., revealed resident was lowered by an aide to the knees during the transfer from a recliner to a wheelchair. The resident became weak during the transfer and needed to be lowered to the ground, unable to complete the transfer. The resident had slight redness to the right knee but denied pain/discomfort. The resident was able to stand and was placed in a wheelchair with two staff assistants. Review of the facility documentation, and fall investigation, revealed that on February 26, 2023, at 1:43 p.m., the resident was lowered to their knees during a transfer from a recliner to the wheelchair. Records revealed non-licensed employee E3 transferred the resident by herself/himself. Review of non licensed Employee E3's statement dated March 8, 2023, revealed that she/he was aware of the resident's care plan to have two-person assistance with transferring, but the other aide was not on the unit and the nurse was occupied assisting another resident. Interview with the Director of Nursing on March 30, 2023, at 10:00 a.m., confirmed that the facility failed to ensure Resident 91 was free from neglect by not providing two-person assistance with transferring contributing to the resident's fall. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review and interviews with staff, it was determined that the facility failed to follow physician orders and failed to follow a wound doctor's wound recommendation for 2 out of 22 residents reviewed (Resident 87 and Resident 102). Findings include: Review of Resident 87's clinical record revealed a diagnosis of Hypertensive Chronic Kidney Disease (high blood pressure is caused by kidney disease). Further review revealed a physician's order for Metoprolol Succinate Extended Release (24-hour) tablet of 25mg (a medication that helps lower blood pressure) to be given a half tablet (12.5 mg) by mouth two times a day. Hold if heart rate is less than 60. Call if the blood pressure is less than 90/60 or greater than 160/100. Review of Resident 87's Medication Administration Record (MAR) revealed on the morning of December 9 and December 19, 2022, the medication was given when the resident's heart rate was below 60 (57 and 58 respectively) and in the evening on December 27 and 28, 2022, (55 and 52). Further review of the March 2023 MAR revealed that the resident received Metoprolol on March 21 and March 22 in the evening when the resident's heart rate was below 60 (recorded as 53 and 55 respectively). Interview with the Nursing Home Administrator on March 30, 2023, at 8:50 a.m. revealed that the medication was not given according to physician's orders for the dates mentioned above. Review of Resident 102's clinical records and wound evaluation report revealed resident was admitted to the facility on [DATE], with a wound lesion to the right foot's second toe, with a measurement of 1.0 x 0.9 cm (centimeter). Review of the Nurse Practitioner's (NP) notes dated February 7, 2023, revealed Resident 102 with an open wound to the second toe due to a calloused lesion debrided by a podiatrist (medical specialist that deals with problems affecting feet or lower legs) with problems affecting feet or lower legs). Further review of Nurse Practitioner's progress note revealed resident was to follow up outpatient wound clinic for further treatment and to continue triple antibiotic ointment and band aide until seen by the wound clinic doctor. Review of Resident 102's clinical record failed to reveal a wound treatment order to the right foot second toe initiated and therefore no treatment was completed. Review of Resident 102's wound consult dated February 22, 2023, revealed the right second toe with ulcer and exposed, with prior partial amputation. No acute infection but concern for chronicity. A wound care recommendation was made as follows: Wash the wound with soap and water scrubbing gently. Rinse well, pat dry, apply Iodosorb (Used to treat and kill bacteria in wounds) then cover with Kling. Further review of Resident 102's clinical records failed to reveal the recommended Iodosorb wound treatment was initiated as an order and therefore no treatment to the right foot's second toe was completed. Review of the Treatment Administration Record (TAR) revealed Iodosorb wound treatment to the right foot's second toe was only initiated on March 3, 2023, after another wound clinic consult on March 1, 2023. Additional review of Resident 102's clinical record revealed Resident 102 did not have documented evidence that her/his right foot second toe wound treatment was done from admission, February 6, 2023, until March 2, 2023. Interview with the Director of Nursing was conducted on March 30, 2023, at 10:00 a.m. The Director of Nursing was unable to answer why Resident 102's right foot and second toe open wound upon admission were not treated timely. The Director of Nursing reported that the nurse spoke to the physician regarding the wound consult report on February 22, 2023, but confirmed wound treatment recommendation was not placed as an order and therefore was not done. The facility failed to ensure Resident 102's wound treatment recommendation for an open wound to the right foot and second toe from a wound doctor was implemented. 28 Pa. Code 211.12 (c) Nursing services 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on clinical records review, and staff interview, it was determined that the facility failed to ensure non-pharmacological interventions were attempted, and documented indications were provided before the administration of as-needed anti-anxiety medication for one of 22 residents reviewed (Resident 27). Findings include: Review of Resident 27's physician order dated November 28, 2022, revealed resident with complaints of anxiety and nervousness. An order for Klonopin (medication to treat anxiety) 0.25 mg (milligram) daily as needed was made. Review of Resident 27's December 2022, Medication Administration Record (MAR) revealed that from December 1, 2022, until December 14, 2022, as needed Klonopin was administered to Resident 27 ten times without an appropriate indication and was administered nine times without attempting to provide a non-pharmacological intervention before administering the medication. Interview with the Director of Nursing (DON) was conducted on March 30, 2023, at 10:00 a.m. The Director of Nursing reported the resident asked for the medication. The Director of Nursing confirmed that an appropriate indication other than anxiety should have been documented. The Director of Nursing confirmed a non-pharmacological intervention should have been attempted before administering as-needed anti-anxiety medication to resident 27. The facility failed to ensure appropriate indication was documented and non-pharmacological interventions were attempted before administering as-needed anti-anxiety medication to Resident 27. 28 Pa. Code 211.12 (c) Nursing services 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based upon review of facility policy and procedures, clinical record review and review of investigation documents and statements, it was determined that the facility failed to ensure adequate supervision to prevent accidents for one of one resident reviewed (Resident R1). This was identified as a past non-compliance situation. Findings include: Review of facility policy and procedure titled Special Locking Arrangement, revised March 2020, revealed residents, family members, team members, volunteers and visitors should remain with any resident wearing a Special Locking Arrangement (SLA) when away from resident's neighborhood, and should ensure the transfer of resident directly to other team members upon arrival on neighborhood. Review of Resident R1's Elopement Evaluation dated May 30, 2022, revealed Resident R1 was an elopement risk. Review of Resident R1's diagnosis list revealed Resident R1 had a diagnosis of Alzheimer's (progressive [CONDITION(S)] disease of the brain) dementia. Review of Resident R1's clinical progress notes dated July 1, 2022, revealed Resident's WC [wheelchair] was with maintenance from about 2 to 4:00 [PM] to have anti rollbacks applied to it. While the WC was with maintenance resident was sitting in a recliner in the lounge. After resting an hour or so he became very restless and wanted to move around and self-propel. Around 3:50 resident was placed in a WC to self-propel on the unit. At 1600 [4:00 p.m.] WC was returned, and residents wife came to visit and asked where [resident] was. Staff and wife searched residents room and the entire unit, including the unit on the other side CRN [CLover Ridge North]. Unable to find resident. Notified supervisor. A few short minutes later a staff member found [resident] on CRN in the stairwell. The WC he was using temporarily was at the top of the steps and resident on the bottom of the stairs awake and verbal. Residents own WC has an SLA and would alarm staff to him leaving unit. This temporary chair he needed to use for a few minutes had no SLA applied to it. Supervisor there with resident. Residents wife notified and came over to see resident. Supervisor notified physician. 911 took resident to [hospital] for evaluation. Resident remained very verbal and alert with normal confusion at times while awaiting ambulance. Left via litter at 1700 [5:00 p.m]. Further review of Resident R1's clinical progress notes dated July 1, 2022, revealed Around 16:05 [4:00 p.m.] resident was observed laying on the floor on his left side in the Clover Ridge North [CRN] stairway after he probably attempted to leave the floor. Normally, resident has SLA on his regular wheelchair that would prevent him from exiting the unit. However, since maintenance was placing anti rollbacks on his wheelchair at the time, staff temporarily placed him in another wheelchair so he could self-propel. He was alert and verbal at baseline, did not exhibit any signs or symptoms of distress and no injuries were noted. Resident presents with confusion, poor impulse control, and poor safety awareness related to dementia and Alzheimer's disease and his current BIMS score is 3. He overestimates his physical ability despite impaired physical mobility, generalized muscle weakness and difficulty walking and tends to attempt activities with calling for staff assistance. He does not take aspirin or other anticoagulation. Current fall interventions are to encourage recliner in common area, to keep in dayroom for safety, to keep room free from clutter, to offer recliner in day room when resident is agitated at HS until ready for bed and anti-roll backs to wheelchair to prevent WC from moving back when resident attempts to stand up. New intervention is to place SLA on resident and not on the wheelchair or other assistive devices. Observation of all current residents requiring an SLA device revealed all residents were wearing their SLA devices on their person as well as on their assistive devices. Interviews conducted with staff revealed staff are aware of the SLA devices, monitoring of the devices, and the supervision required for all residents wearing SLA devices. Review of education records revealed all staff and employees from all departments have been educated on the use of SLA devices and continued monitoring of residents requiring SLA devices. Review of all Treatment Administration Records (TAR) of residents requiring SLA devices revealed all residents have the SLA checked daily for function and three times per day for placement. Review of audits revealed that audits have been completed and reviewed for all residents requiring SLA devices to ensure placement and function. Audits will continue to be completed and reviewed by the Director of Nursing. Interview with the Nursing Home Administrator and Director of Nursing on July 12, 2022, at 1:00 p.m. confirmed all the above information and all the above interventions and corrections made in the facility after the incident on July 1, 2022. This has been identified as a past non-compliance situation related to the completion of interventions, education, and audits throughout the facility. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on observation, interviews, and record reviews it was determined the facility failed to ensure the accuracy of assessments for two of 32 residents reviewed. (Residents 29 and 33) Findings Include: Review of Resident 29's quarterly Minimum Data Set (MDS-periodic assessment of resident needs), dated January 18, 2022, revealed the resident had a stage 2 pressure ulcer (wound with partial thickness of skin and tissue). Review of Resident 29's clinical record revealed the resident was only documented having an area of Moisture Associated Skin Damage (MASD- inflammation or skin erosion due to a long time exposure to moisture) at the time of the assessment. Interview with Licensed nursing Employees E3 and E4 on April 7, 2022 at 11:00 a.m. revealed Resident 29 has never had a pressure ulcer and did have an area of MASD at the time of the MDS assessment in January 2022. Review of Resident 33's most recent quarterly Minimum Data Set (MDS-periodic assessment of resident needs), dated January 24, 2022, revealed the resident was coded as having a restraint because the chair that was being used impaired the resident from standing. Observations of the resident and the resident's room on all days of the survey revealed Resident 33 was sitting in a wheelchair in a common area or a recliner in the resident's room next to the bed. Review of Resident 33's clinical record revealed no documented evidence the resident had a restraint in use. Interview with Licensed Nursing Employees E3 and E4 on April 7, 2022 at 11:00 a.m. revealed Resident 33 only either sits in the wheelchair or the recliner and can stand on her own when using either of these chairs. Further interview revealed Resident 33 never was considered having a restraint due to using a chair. Interview with the Nursing Home Administrator and Director of Nursing on April 7, 2022 at 11:45 a.m. confirmed the MDS assessments for Residents 29 and 33 were coded inaccurately. 28 Pa Code 211.5(f) Clinical Records 28 Pa Code 211.12(d)(1)(3)(5) Nursing Services

Based on observation, review of facility policy, and staff interviews, it was determined that the facility failed to ensure the food temperature policy included parameters identifying safe beverage temperatures for hot liquids resulting in actual harm to one resident who sustained [CONDITION(S)] on the anterior and lateral right thigh. This resulted in an Immediate Jeopardy situation when it was determined that the policy failed to identify hot beverage temperature parameters which had the potential to cause the residents discomfort or pain, to jeopardize the health and safety of 27 residents of 102 total skilled nursing residents. Findings Include: Review of facility policy titled, Serving Hot Liquids/Dining Area, with a revision date of March 2010, revealed in final bullet point, For dining in the remote dining areas, the temperature of hot beverages and soups will be recorded by the dining room server at time of meal service. Temperature of hot liquids must not be less than 130 degrees at the time of delivery to the resident. Further review of the facility policy does not include highest safe temperature for hot liquids. Review of clinical record of Resident R1 revealed that resident was admitted on [DATE], with diagnoses including but not limited to the following: dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), adult failure to thrive, hypertension (high blood pressure), [CONDITION(S)] (irregular heartbeat), and heart failure. Progress note dated April 16, 2021, at 9:01 p.m. by the Registered Nurse revealed, Resident spilled coffee at supper on RLE (right lower extremity) resulting in redness area with blisters (1st and 2nd degree burn) on upper R (right) thigh. New order from provider for [MEDICATION(S)] BID and non- adherent pad daily and monitor for s/s (signs/symptoms) of infection. Further review of progress notes revealed a progress noted by licensed staff dated April 16, 2021, at 11:34 p.m. which indicated, The area of [CONDITION(S)] was 8 inches wide by 3.5 inches long. With 3 areas of peeling skin. The larges area was 7.0 cm in diameter, second 3.0 cm in diameter, and third 2.0 cm in diameter. Review of documentation submitted by the facility on April 16, 2021, at 5:00 p.m. revealed, the homemaker told charge nurse, [resident] had spilled [resident] coffee in [resident] lap. Resulting in burn to right upper thigh. Review of facility provided investigation documentation revealed Nurse Aide, Employee E10's written statement indicating, I went to get the coffee and put it in a blue insulated mug with a lid on it. I placed it on the table where [resident] could reach it. Since dinner service had been served, I went to the northside to assist [dietary aide] with those residents I was not present when the spill happened. I noticed [Resident] had the lid off the mug and there was no coffee left, I assumed [resident] drank it. A while later, one of the aides or nurses mentioned [resident] had spilled [resident] coffee. Interview on April 26, 2021, at approximately 10:58 a.m. with Dietary Aide, Employee E3, revealed that meal items and hot beverages have temperatures taken prior to service. Employee E3 stated that hot beverage temperatures, are usually between 150-160. When asked the procedure for identifying unsafe hot beverage temperatures, Employee E3 was unable to identify any procedure. Interview on April 26, 2021, at approximately 11:05 a.m. with Dietary Aide, Employee E8, the employee indicated that the temperature of the coffee in the push pump carafe registered 160 degrees at 11:00 a.m. Employee E8 stated, the coffee is still from breakfast. Employee E8 was questioned regarding safe serving temperature of hot beverages to which Employee E8 replied, above 140 but probably not hotter than 180. Employee E8 was unable to identify process if a staff member were to note unsafe beverage temperatures. Telephone interview on April 26, 2021, at approximately 1:49 p.m. with Registered Nurse Employee E5, who was on the unit at the time of the event stated, Homemaker came over and said that [resident] spilled coffee on self. I went over to [resident] and noted clothing (shirt and pants) were wet. I grabbed a blanket to dry [resident] off. I looked under the clothes and the skin looked normal. The clothes felt warm. I went and asked the nursing assistant to help me change [resident]. We took [resident] to the bathroom and saw that [resident's] upper thigh- anterior to lateral thigh was red. The skin looked loose like it was going to blister. I notified the supervisor and faxed the physician and called the on-call physician. Review of the April 16, 2021, temperature logs for skilled nursing unit Harvest View South, revealed a temperature of 180 degrees taken at 4:35 p.m. for decaf (decaffeinated) coffee. Further review of the temperature log did not reveal a recommended temperature range for hot beverages. Interview with Employee E7, Dietary Manager, on April 26, 2021, at approximately 2:43 p.m. revealed, facility policy does not have a hot beverage range identified. Dietary Manager denied knowledge of how staff should identify unsafe hot beverage temperatures nor what process staff should initiate for unsafe consumption of hot beverages. There was no evidence that the facility could identify when temperatures of hot beverages exceed a safe temperature for consumption and/or a course of action for if safe consumption temperatures are exceeded. An Immediate Jeopardy situation was identified on April 26, 2021, at 5:36 p.m. and the Immediate Jeopardy template was presented to the Nursing Home Administrator, the Director of Nursing, and the Executive Director at 5:38 p.m. on April 26, 2021, regarding the facility's failure to ensure the prevention of first and second degree [CONDITION(S)] sustained by one resident and placing additional residents at risk of serious [CONDITION(S)] due lack of policy and practice identifying unsafe beverage temperatures during meal service. The facility submitted and completed an immediate action plan which included completing resident hot liquid safety assessments for all current residents and audits of hot liquids on each skilled nursing unit. The facility staff were educated on an updated hot beverage policy which indicated that hot beverages should have a temperature of 150-155 to be deemed safe for service. The policy also indicated the action staff are to take if hot beverages are above the stated rage of 150-155 degrees. The staff are directed to wait for the hot beverage to cool and retake the temperature to ensure it's below 155 degrees before servicing resident. Education and competencies were given to nursing staff regarding identification of and procedure to remedy unsafe beverage temperatures prior to the start of their work shift. The Director of Nursing or designee will complete random audits to verify hot liquid temperatures at meal service for subsequent five days and then weekly for next four weeks and report audit results to the QAPI (Quality Assurance and Performance Improvement) team. Education was provided by the Nursing Home Administrator, the Director of Nursing, and the RN Supervisor regarding the safe beverage temperature range of 150-155 degrees and the procedure if unsafe beverage temperatures were identified. The Nursing Home Administrator or designee will do audits every shift daily for four weeks to ensure that hot beverages are served at safe consumption temperatures. The action plan was accepted on April 26, 2021, at 7:41 p.m. On April 27, 2021, a review of audits, documentation of completed employee education, and interviews with 41 staff members revealed the facility had completed the interventions developed for the action plan. The Immediate Jeopardy was lifted on April 27, 2021, at 3:01 p.m. after confirmation the immediate action plan was implemented, and the Nursing Home Administrator and the Director of Nursing were informed the residents were no longer in immediate jeopardy. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on a review of their job descriptions it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure the food temperature policy included parameters identifying safe beverage temperatures for hot liquids and failed to protect residents from potentially suffering a medical emergency related to hot beverage [CONDITION(S)]. Findings include: Review of the job description for the NHA revealed the essential function is to oversee and effectively manages processes, protocols, policies, programs, and activities on behalf of residents in skilled areas. Proactively implements and evaluates enhancements to policies and programs to meet the needs of residents and promote their physical, cognitive, and social well being. Maintains a safe, comfortable, and functional environment by evaluating [skilled and rehabilitation center] for potential hazards, and working with other managers to implement effective practices regarding sanitation, infection control, fire safety, disaster preparedness, and emergency care. Review of the job description for the DON revealed the responsibility of the job position is to communicate and promote high quality, Resident centered nursing practices among all staff; and proactively assists the Administrator to oversee and manage the [skilled nursing units] in an efficient and effective manner. The DON performs all duties in strict adherence to applicable federal, state, and local regulations including HIPAA, Department of Health regulations, and the Elder Justice Act in accordance with sound and effective clinical practices; and with the highest degree of integrity consistent with Brethren Village's core values. The findings in this report identified that the facility failed to ensure that residents were served hot beverages at a safe consumption temperature which placed residents in Immediate Jeopardy. The facility staff failed to identify hot beverage temperature parameters. The NHA and DON failed to fulfill their essential job duties that the federal and state guidelines and regulations were followed. Refer to F689 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 207.2(a) Administrator's Responsibility 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa. Code 211.12(d)(2)(3) Nursing Services

Based on resident interview, facility record review and staff interview, it was determined that the facility failed to ensure resident safety for two of 23 residents reviewed (Resident #39 and Resident #83). Findings include: An interview was conducted on (MONTH) 15, 2019 at approximately 10:47 a.m. with Resident #39. During the interview Resident #39 revealed that she had a recent fall where she was hurt. Review of Resident #39's clincal record revealed that on (MONTH) 28, 2019, the resident asked two nursing assistants to get her up using a sit to stand mechanical lift. During the transfer the resident was unable to complete the task and was placed back into her wheelchair. Further review of Resident #39's clinical record revealed that later that same morning Resident #39 complained of ankle pain. Review of Resident #39's Quarterly Minimum Data Set (MDS- an assessment tool) dated (MONTH) 14, 2019, Section G Functional Status identified the resident as requiring total dependance of two staff for transfers. Further review of Resident #39's care plan initiated (MONTH) 19, (YEAR) identified the resident requiring assistance with transfers and mobility. The interventions included the use of a hoyer lift (mechanical device use to transfer a resident up from one surface to another) An interview with the Director of Nursing was conducted on (MONTH) 18, 2019 at approximately 10:30 a.m. revealed that residents have a care plan for transfer status which was determined by therapy. It was expected that the staff follow the resident's care plan until therapy has determined another transfer alternative. Nursing assistants should not make this determination on their own. The facility failed to ensure that Resident #39 was transfer out of the wheelchair via hoyer lift and with the use of a sit and stand mechanical lift. Review of Resident #83's care plan initiated on (MONTH) 21, (YEAR) identified the resident as at risk for falls related to weakness, a cognitive decline, and poor safety. Review of Resident #83's Person Centered Care Form, initiated on (MONTH) 21, (YEAR) and last updated (MONTH) 25, 2019, revealed interventions in place to prevent falls included fall mats to both sides of the resident's bed and to offer to keep the wheelchair at the resident's bed side. Review of Resident #83's clinical record revealed that the resident had a fall out of bed on (MONTH) 28, (YEAR) at 11:00 p.m. Review of facility documentation revealed that the resident's fall mat was down on the opposite side of the resident's bed, but not on the side that the resident landed on. The intervention added to Resident #83's care plan was to educate team members regarding placing bilateral fall mats down. Further review of Resident #83's clinical record revealed that the resident was found on the floor of her room by her dresser on (MONTH) 26, 2019 at 10:30 p.m. Review of facility documentation revealed that at the time of the resident's fall, the resident's wheelchair was stored in the resident's bathroom. The intervention added to Resident #83's care plan was education to staff to offer to keep the wheelchair at the resident's bedside. The facility's failure to follow Resident #83's Person Centered Care Form was discussed and confirmed with the Director of Nursing on (MONTH) 18, 2019 at 12:45 p.m. 28 Pa. Code: 211.10 (d) Resident care policies. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Based on a review of facility policy, clinical record, review of information submitted by the facility and staff interview, it was determined that the facility failed to report an allegation of neglect to the Pennsylvania Department of Aging in accordance with the Older Adults Protective Services Act for one of three residents reviewed (Resident C3). Findings include: Review of the Older Adults Protective Services Act (OAOSA), mandates reporting requirements on suspected abuse. Any employee of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local Area Agency of Aging and licensing agencies. If suspected abuse involves serious physical injury as defined under OAOSA the law requires additional reporting to the Department of Aging and local law enforcement. Review of facility policy Freedom from Abuse, Neglect and Exploitation reviewed (MONTH) (YEAR), indicated that if abuse involves serious physical injury, serious bodily injury, suspicious death, or elopement, the facility is required to immediately report the incident to the local police; the local Area Agency on Aging; Pennsylvania Department of Aging and the Division of Nursing Care Facilities at the local field office during normal business hours. Review of Resident C3's nursing notes dated (MONTH) 9, (YEAR), revealed that the resident was lowered to the floor by non licensed Employee E4. Further review of Resident C3's clinical record revealed that an X-ray of the resident's right leg revealed an acute fracture of distal medial femoral condyle (thigh bone). Review of facility investigation into the fall incident sustained by Resident C3 determined that Employee E4 did not follow procedure of utilizing a gait belt for the resident during a transfer when the resident stated she was not sure if she could stand. Interview with the Director of Nursing (DON) on (MONTH) 12, (YEAR), at 11:50 a.m. revealed that the facility investigation determined that the resident's injury was not consistent with Employee E4's statement and it was decided that the injury was the result of abuse. Review of the information submitted by the facility to the State agency revealed that the Pennsylvania Department of Aging was not notified of Resident C3 serious physical injury as a result of abuse until (MONTH) 8, (YEAR). The DON on (MONTH) 12, (YEAR), at 11:50 a.m. confirmed that the Pennsylvania Department of Aging was not notified in a timely manner. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 5/23/17 28 Pa. Code 201.18(b)(1) Management Previously cited 5/23/17 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 5/23/17 28 Pa. Code 211.12(d)(3) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure significant medication errors for one of three residents reviewed (Resident CL1). Findings include: Review of Resident CL1's clinical record revealed on June 1, 2017, hospice services were initiated. Review of June 2017 physician's orders [REDACTED]. Review of Resident CL1's June 2017 Medication Administration Record [REDACTED]. An interview conducted with the Director of Nursing on November 28, 2017 at approximately 11:30 a.m. revealed the nurse transcribed the medication order for [MEDICATION NAME] 6 milligrams as needed every 4 hours incorrectly into the computer system. The facility failed to ensure Resident CL1 was free of significant medication errors. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 05/23/2017, 11/17/2016

Based on clinical record review and staff interview, it was determined the facility failed to ensure that physician's orders were followed for five of 23 residents reviewed (Residents: F4, G6, H2, I10, J2) Findings Include: Review of Resident F4's physician's orders revealed an order dated January 19, 2017 for [MEDICATION NAME] (short acting antianxiety medication) 0.5 mg (milligrams) once daily at 4:30 pm. Review of Resident F4's progress notes revealed a nursing entry on March 10, 2017 stating resident was scheduled [MEDICATION NAME] at (4:30 pm) on March 9, 2017. Noticed that it wasn't signed out on (narcotic) sheet but was marked as accepted. Review of Resident F4's March 2017 Medication Administration Record [REDACTED]. Review of Resident G6's physician's orders revealed an order dated November 14, 2016 for [MEDICATION NAME] 0.25 mg twice daily. Review of Resident G6's progress notes revealed a nursing entry on November 17, 2016 stating It was brought to my attention that a medication error had occurred. [MEDICATION NAME] was decreased from 0.5 mg to 0.25 mg. Order was transcribed incorrectly and pharmacy never changed the cassette to the proper dosage of [MEDICATION NAME]. Review of Resident G6's November 2016 Medication Administration Record [REDACTED]. Review of Resident H2's physician's orders revealed an order for [REDACTED]. Interview with the Director of Nursing on May 22, 2017 at 1:30 pm confirmed that on May 20, 2017, the Resident H2 was given [MEDICATION NAME] instead of the prescribed Klonopin. Review of Resident I10's physician's orders revealed a communication to the physician on November 10, 2016 stating that Resident I10's [MEDICATION NAME] (narcotic pain medication) was mistakenly omitted on November 9, 2016. Review of Resident I10's progress notes revealed a nursing entry on January 15, 2017 stating the resident January 14, 2017 6:00 p.m. [MEDICATION NAME]-[MEDICATION NAME] (medication to treat [MEDICAL CONDITION] (A disorder of the central nervous system that affects movement, often including tremors) disease) and Entacipone (medication to treat [MEDICAL CONDITION]) were omitted. Interview with the Nursing Home Administrator on May 22, 2017 at 10:45 confirmed that Resident I10 did not receive the narcotic medication and the medications ordered to treat [MEDICAL CONDITION] as ordered by the physician. Review of Resident J2's physician orders revealed an order dated February 24, 2017 to apply a [MEDICATION NAME] Border (foam bandage with adhesive outer ring) for protection and change every three days or as needed if soiled for a reddened area near the resident's sacrum (triangular bone at the base of the spine). Review of Resident J2's progress notes revealed a nursing entry on March 4, 2017 stating resident noted to have [MEDICATION NAME] Border on sacrum dated February 24, 2017. Order for [MEDICATION NAME] border to sacrum to be changed every three days and charge nurse signed off that dressing was changed February 28, 2017 and March 3, 2017. Interview with the Nursing Home Administrator on May 22, 2017 at 10:45 a.m. confirmed that this resident did not receive the treatment of [REDACTED]. 28 Pa Code: 211.5 (f) Clinical records Previously cited: 3/15/2016 28 Pa Code: 211.10 (c) (d) Resident Care Policies Previously cited: 3/15/2016 28 Pa Code: 211.12 (d) (1) (5) Nursing Services Previously cited: 3/15/2016

Based on observation, review of clinical records, and review of facility documentation, it was determined that the facility failed to put interventions in place to prevent falls and failed to provide supervision during medication administration for two of 23 residents reviewed (Resident F4 and Resident K1). Findings include: Review of Resident F4's clinical record revealed [DIAGNOSES REDACTED].(a progressive disorder of the nervous system that affects movement), and a history of falls. Review of Resident F4's plan of care for falls revealed that an intervention was put in place on December 1, 2016 for focused supervision during periods of restlessness. Review of facility documentation revealed that Resident F4 had an unwitnessed fall in the Harvest Way North living room on January 28, 2017 at 9:00 pm. The corrective measure listed in the documentation was to offer (Resident F4) distraction with activity. Review of Resident F4's plan of care for falls revealed that offering the resident distraction with activity was an intervention that was already put in place on December 1, 2016. Review of facility documentation revealed that Resident F4 had an unwitnessed fall in the Harvest Way North living room on February 3, 2017 at 8:00 pm. Review of facility documentation revealed that Resident F4 had an unwitnessed fall in the Harvest Way North living room on February 24, 2017 at 9:15 pm. The corrective measure listed in the documentation was to offer (Resident F4) toileting frequently. Review of Resident F4's plan of care for falls revealed that offering the resident frequent toileting was an intervention that was already put in place on February 13, 2017. Review of facility documentation revealed that Resident F4 had an unwitnessed fall in the Harvest Way North living room on March 29, 2017 at 8:15 pm. The corrective measure listed in the documentation was to continue offer toileting .or encourage him to do an activity. Review of Resident F4's plan of care for falls revealed that offering activities and toileting were interventions that were already supposed to be in place from December 1, 2016 and February 13, 2017. Resident F4's four unwitnessed falls in the living room in the evening time, along with the lack of new interventions put in place to prevent falls, were discussed with the Nursing Home Administrator on May 23, 2017 at approximately 11:45 am. Observations conducted on May 22, 2017 at 8:45 a.m. on the Clover Ridge South Unit dining room revealed Resident K1 sitting at a table with a napkin on the table and approximately fifteen pills laying on the napkin. The resident was observed over a period of fifteen minutes picking one pill up at a time and swallowing them. Further observation revealed there was no nursing staff observing this resident taking her medications to ensure that she took all of them or that any other residents had not come to this resident and taken the medications. Interview conducted with licensed nursing Employee E4 on May 22, 2017 at 9:10 a.m. revealed that she was assigned to this resident and had given her medications to take on her own, however had not observed the resident taking the medications because she was in the nursing station attending a meeting. Interview with the Nursing Home Administrator on May 23, 2017 at 10:45 a.m. confirmed that the resident should have been observed by nursing staff while administering herself the medications. The facility failed to developed interventions to prevent further falls for Resident F4 and to provide supervision during medication administration for Resident K1. 28 Pa. Code: 201.14 (a) Responsibility of licensee.Previously cited 3/15/2016 28 Pa. Code: 201.18 (b)(1)(e)(1) Management.Previously cited 11/17/2016, 3/15/2016 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services. Previously cited 11/17/2016, 3/15/2016

Based on review of facility policy and procedure, review of closed clinical records, facility documentation and staff interview, it was determined the facility failed to ensure the proper accountability and disposition of narcotic medications for one of three residents reviewed (Resident CL2). Findings include: Review of facility policy and procedure, entitled Discharges and/or Transfers, revision date [DATE], for the disposition of discontinued drugs for a deceased resident, revealed three procedure steps: Step 1 proceeded for medications to be returned to pharmacy for disposal. Step 2 proceeded for medications to be counted and documented in the printed electronic Medication Administration Record [REDACTED]. Review of Resident CL2's closed clinical record revealed that the resident expired at facility on [DATE]. Review of Resident CL2's individual controlled medication report for Roxanol (pain medication) 20 milligrams/milliliters with direction for usage of three drops every four hours as needed for pain and shortness of breath documented that the balance remaining on [DATE] was 561 milliliters. Review of Resident CL2's individual controlled medication report for Roxanol 20 milligrams/milliliters with direction for usage of 10 drops every four hours and every one hour as needed for pain documented that the balance remaining on [DATE] was 110 milliliters. Interview with the Nursing Home Administer, on [DATE] at approximately 9:50 a.m. confirmed that facility had no documented evidence for the disposition and return to pharmacy the pain medication, Roxanol, for deceased resident, Resident CL2. Facility could not provide evidence that the medication was disposed to the pharmacy. Facility failed to document the quantity and disposition of Resident CL2's narcotic medication following discharge from the facility. 28 Pa. Code: 201.14(a) Responsibility of licensee Previously cited [DATE] 28 Pa. Code: 201.18(b)(1) Management Previously cited [DATE] and [DATE] 28 Pa. Code: 211.5(f) Clinical records Previously cited [DATE] 28 Pa. Code: 211.9 (a)(1) Pharmacy Services Previously cited [DATE] 28 pa. Code: 211.9(j) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited [DATE] and [DATE]

Based on a review of facility documentation and staff interview, it was determined that the facility failed to ensure that two of two alleged violations of resident abuse were thoroughly investigated and reported to the State agency in accordance with the state law. (Resident A1 and A2) Findings include: Review of a PB-22 Report Form for Investigation of Alleged abuse, Neglect and Misappropriation of Property involving Resident A1 revealed that the resident alleged on October 11, 2016 at 8:00 a.m. two black women ripped her night gown off her an tore it in to strips and tied her to the bed. Interview conducted with the Administrator and the Director of Nursing on November 16, 2016 at 4:00 p.m. confirmed that the investigation was completed on one of the employees who provided care to Resident A1 on October 11, 2016 but there was no investigation and report to the State agency on the second employee who was also present during the provision of care to Resident A1 on October 11, 2016. Review of a PB-22 Report Form for Investigation of Alleged abuse, Neglect and Misappropriation of Property involving Resident A2 revealed that the resident's family reported to the facility that on September 22, 2016 the resident's family member called the resident on the phone and the phone was answered by a staff member who indicated that the resident was been transferred from the bed to the chair and indicated for the resident's family member to wait on the phone until the transferred was completed in order to speak to the resident. The residnet's family reported to the facility that the following loud statements were made by one of the two employees who was providing care to Resident A 2: what did you?, why did you do that?; how come you did not act like this in the hospital? Interview conducted with the Administrator and the Director of Nursing on November 16, 2016 at 4:00 p.m. confirmed that the investigation was completed on one of the employees involved during the transferred of Resident A2 from bed to chair on September 22, 2016 but there was no investigation and report to the State agency on the second employee who was also present during the provision of care to Resident A2 on September 22, 2016. 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 201.18(b)(1) Management

Based on review of the clinical record, review of facility policy and staff interview, it was determined that the facility failed to ensure the safe use of the hoyer lift device to transfer a resident which resulted in actual harm to one out of 24 residents reviewed (Resident E13). Findings include: Review of the resident's current [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS assessment (a periodic assessment of the resident's identified needs and abilities) dated June 5, 2012 revealed that the resident was totally dependent on staff for transfer and required two persons for transfer. Review of the facility policy for transfers utilizing a portable mechanical lift dated April 2011 revealed that two persons were to assist whenever a mechanical lift is used to transfer a resident.. Review of nurses notes dated August 30, 2012 at 3:57 p.m. related that Resident E13 was being transferred from the chair to bed with a hoyer lift with one assist. The rexident complained of shoulder pain. Review of the facility reported event dated August 30, 2012 at 3:40 p.m., related that the resident was being transferred in the Hoyer lift and slid out of the sling and hit the floor. On initial assessment the resident denied pain but as the shift progressed the resident complained of increased pain including chest pain. The physician was notified and ordered the resident sent to the emergency room for evaluation secondary to pain and anticoagulant use. The resident was admitted to the hospital with [REDACTED]. Facility documentation also related that on August 30, 2012 at 3:40 p.m., the nursing assistant admitted to the licensed nursing employee E3, that she had transferred the resident alone rather than getting the second required assistant necessary for the mechanical lift resulting in injury to the resident. The Nursing Home Administrator confirmed these findings on September 13, 2012 at 2:00 p.m. Failure of staff to provide two person transfer resulted in actual harm to the resident. F323 Previously cited 3/9/12 28 Pa. Code 211.10 (d) Resident Care Policies Previously cited 3/9/12 28 Pa. Code 211.12 (d)(1)(5) Nursing Services Previously cited 3/9/12