Every finding on record at Brookview Health Care Center

Based on a review of facility policies and employee personnel files, it was determined that the facility failed to ensure that a licensure check was completed before hire for one of five employee files reviewed (Registered Nurse 1).Findings include:The facility's policy for abuse, dated February 27, 2026, indicated that potential employees would be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. Background, reference, and credential checks would be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants.Review of the employee file for Registered Nurse 1 indicated that she was hired on December 29, 2025. There was no documented evidence that her professional license was checked to ensure it was current and that she had no disciplinary action filed.Interview with the Nursing Home Administrator on March 27, 2026, at 10:43 a.m. confirmed that they could not find any documented evidence that the licensure check was obtained prior to hire. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(1) Management.

Based on review of facility policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice by failing to follow physician's orders for three of 24 residents reviewed (Residents 17, 32, 56). Findings include: The facility's policy regarding medication administration, dated April 11, 2024, revealed that medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. An annual Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 17, dated February 5, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnosis that included dementia. Physician's orders for Resident 17, dated October 17, 2024, indicated that the resident was to have her wound cleansed with saline and a gauze pad, provide soft debridement, apply Hydrofera Blue Transfer (a foam dressing used to treat wounds) to the wound, apply Unna boots (compression bandage that treats leg wounds, ulcers, and swelling) to her bilateral lower extremities, and put a cover sponge or foam dressing over the foot dorsum (top of foot) after the Unna boot layer every night shift on Tuesday, Thursday, and Sunday. Physician's orders for Resident 17, dated October 25, 2024, included to cleanse the resident's left leg wound with a sterile saline gauze pad, provide mechanical debridement to wound as tolerated by patient, apply Hydrofera Blue to the wound, and a single layer Unna boot compression from the base of the toes and up over her calf to just below the popliteal crest (behind the knee). Offload (reduce pressure on a painful or sensitive area) the prominent tibial crest (shin bone) and anterior tibialis tendon (tendon - attaches muscle to bone, that runs from the front of the shin to the front of the foot) with a dry dressing. Place a cover sponge or foam pad over the foot dorsum after the Unna layer to add extra compression to edema (accumulation of excess fluid) every day shift, every Tuesday, Thursday, and Sunday. Physician's orders for Resident 17, dated January 2, 2025, included to cleanse the wound and leg with sterile saline or wound cleanser with sterile gauze pads. Apply Mepilex transfer (type of dressing used to treat wounds) over the wound and over the Achilles tendon (connects calf muscle to the heal). Apply a single layer of Unna boot compression from the base of toes and start of knee crease. Use strips of cast padding along either side of the tibial crest and Achilles tendon for offloading. Apply a rolled gauze layer and Coban (self-adhering bandage) layer. Change twice a week when not seen in the wound clinic the same week, once a week when the resident is seen in the wound clinic, at bedtime every Monday and Thursday for wound care and edema. Review of the Treatment Administration Record (TAR) for Resident 17, dated October 2024, revealed no documented evidence that treatment was provided to the resident's leg on October 17, 20, and 25, 2024, as ordered. Review of the TAR, dated February 2025, revealed that the resident's treatment was completed on February 3 and 6, 2025. Review of wound clinic visits revealed that the resident was seen in the wound clinic on February 5, 2025. Interview with the Director of Nursing on February 4, 2025, at 1:35 p.m. confirmed that Resident 17's treatment to her left lower leg was not completed per physician's orders on October 17, 20, and 25, 2024, and that the treatment was completed twice in one week on February 3, and 6, 2025, when it should have been changed only once because the resident was seen in the wound clinic on February 5, 2025. A quarterly MDS assessment for Resident 32, dated January 24, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, had diagnosis that included dementia, and was receiving hospice services. Physician's orders for Resident 32, dated December 16, 2024, included for the resident to receive a 25 microgram per hour (mcg/hr) Fentanyl patch (skin patch is used to treat severe pain) applied every 72 hours for pain. Review of the Medication Administration Record (MAR) for Resident 32, dated December 2024, and the narcotic accountability sheet, dated December 16, 2024, indicated that the resident was administered a 25 mcg/hr Fentanyl patch on December 24, 2024, and on December 28, 2024. Interview with the Director of Nursing on February 26, 2025, at 11:45 a.m. confirmed that the 25 mcg/hr Fentanyl patch was not administered every 72 hours as ordered for Resident 32 between December 24, 2024, and December 28, 2024. Admission paperwork for Resident 56 indicated that the resident was admitted to the facility on [DATE]. Physician's orders for Resident 56, dated February 14, 2025, included for the resident to receive a 5 milligrams (mg) Midodrine (medication for low blood pressure) three times per day. A nursing note for Resident 56, dated February 17, 2025, revealed that the nurse practioner ordered parameters for the Midodrine to be held if the resident's systolic (top number) blood pressure was greater than or equal to 120 and if the diastolic (bottom number) was greater than or equal to 70. Review of the MAR for Resident 56, dated February 2025, indicated that the parameters for the Midodrine were not added to the order and the resident received the medication on from February 14 through 17 without his blood pressure being monitored. Physician's orders for Resident 56, dated February 17, 2025 revealed that the resident was to receive 5 mg Midodrine three times per day for low blood pressure and that staff were to hold the medication if the resident's systolic blood pressure was greater than or equal to 120 or the diastolic blood pressure was greater than or equal to 70. Review of the MAR for Resident 56, dated February 2025, revealed that on February 19 the resident's blood pressure was 132/76 and on February 20 the resident's blood pressure was 128/66. The MAR indicated that the resident received the Midodrine both times; however, according to parameters, the resident's Midodrine should have been held. Interview with the Director of Nursing on February 25, 2025 at 11:46 a.m. confirmed that Resident 56's Midodrine order for parameters was missed from February 14-17 and that he should not have received the Midodrine on February 19 or 20, 2025. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on observations and staff interviews, it was determined that the facility failed to ensure that ice was made and stored in sanitary ice machines for one of two ice machines ([NAME] House). Findings include: Observations of the ice machine in the [NAME] House pantry on February 24, 2025, at 8:16 a.m. and February 25, 2025, at 9:16 a.m. revealed that the drain pipe coming from the ice machine extended down to the floor and ran horizontally to the floor drain, resulting in no air gap between the end of the ice machine's drain pipe and the floor drain. Interview with Maintenance Worker 1 on February 25, 2025, at 9:27 a.m. confirmed that the ice machine in the [NAME] House Kitchen did not have an air gap between the drain pipe and the floor drain for back-flow prevention. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to review and revise care plans for one of 24 residents reviewed (Resident 11). Findings include: The facility's policy regarding care plans, dated April 11, 2024, revealed that the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). A quarterly MDS assessment for Resident 11, dated January 24, 2025, revealed that the resident was understood, could usually understand others, and had a diagnosis which included Alzheimer's disease and dementia. A care plan for the resident, dated May 5, 2023, revealed that the resident was at risk for malnutrition related to his impaired mobility and dementia diagnosis. Staff was to place a non-adherent material under his plates and bowls at all meals. Observations of Resident 11 during the lunch meal on February 25, 2025, at 12:15 p.m. revealed that the resident was sitting at a table in the dining area on the [NAME] unit feeding himself his lunch meal. There was no non-adherent material under his plate. Resident 11's current care plan, as of February 25, 2025, revealed that staff was to place non-adherent material under his plates and bowls at all meals. Interview with the Director of Nursing on February 25, 2025, at 12:28 p.m. confirmed that Resident 11 did not have non-adherent material under his plates. Interview with the Director of Nursing on February 25, 2025, at 1:40 p.m. confirmed that Resident 11's care plan should have been revised to reflect the discontinuation of the non-adherent material under his plates and bowls at all meals. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for one of 24 residents reviewed (Resident 32). Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 32, dated January 24, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, had diagnosis that included dementia, and was receiving hospice services. Physician's orders for Resident 32, dated November 4, 2024, included for the resident to receive 0.25 milliliters (ml) of Morphine Sulfate Oral Solution (controlled pain medication) 20 milligrams per five milliliters (20mg/5ml) every hour as needed for breakthrough pain. Review of Resident 32's medication accountability sheet (tracks each dose of a controlled medication), dated October 19, 2024, indicated that 0.25 ml of Morphine Sulfate Oral Solution 20mg/5ml was signed out to be administered on December 20, 2024, at 8:33 p.m.; December 21, 2024, at 7:49 p.m.; and on January 7, 2025, at 9:11 a.m. and 3:30 p.m. Review of the Medication Administration Record (MAR) for Resident 32, dated December 2024 and January 2025, revealed no documented evidence that 0.25 ml of Morphine Sulfate Oral Solution 20mg/5ml was administered on the above-mentioned dates and times. Interview with the Director of Nursing February 26, 2025, at 8:54 a.m. confirmed that there was no documented evidence that the signed-out doses of Morphine Sulfate were administered to Resident 32 on the above-mentioned dates and times. 28 Pa. Code 211.9(j.1)(3) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) for one of 24 residents reviewed (Resident 52). Findings include: The facility's policy regarding Trauma Informed Care, dated April 11, 2024, revealed that it is the policy of the facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), Admission Assessment, the history and physical, the social history/assessment, and others. The facility will identify triggers which may re-traumatize residents with a history of trauma. In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident. An Admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 52, dated September 23, 2024, and a quarterly MDS assessment, dated December 23, 2024, revealed that the resident was usually understood, could understand others, and had diagnoses that included dementia and PTSD. Trauma Informed Care Assessments for Resident 52, dated September 23, 2024, and December 23, 2024, revealed that the resident's comment was I don't know. All of the other questions were left blank. A Psychogeriatric (a medical specialty that focuses on the mental health of older people) note for Resident 52, dated September 19, 2024, revealed that the resident has a history of depression and PTSD (per record), as well as a history of crying episodes, anxiety, and nightmares, and has been heard screaming upon awakening since September 2023. However, there was no documented evidence that the facility completed the questionnaires for Resident 52 or asked others to identify specific triggers that could re-traumatize the resident. Interview with the Infection Preventionist on February 26, 2025, at 12:15 p.m. confirmed that there was no documented evidence of further attempts to identify specific triggers that could re-traumatize Resident 52. 28 Pa. Code 211.12(a)(d)(3)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a written notice was provided to the resident's responsible party regarding the reason for transfer to the hospital for two of 24 residents reviewed (Residents 2, 13). Findings include: An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated January 24, 2025, revealed that the resident was cognitively intact and required assistance from staff for her daily care needs. Nursing note for Resident 2, dated January 17, 2025, revealed that the resident was vomiting, nauseous, and had a low blood sugar. The physician was notified and an order was received to transfer the resident to the emergency room , and her son was present and agreed with the transfer. There was no documented evidence that a written notice of Resident 2's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer to the hospital on January 17, 2025. A quarterly MDS assessment for Resident 13, dated January 23, 2025, indicated that the resident was understood, could understand others, and was cognitively intact. The physician was notified and an order was received to transfer the resident to the emergency room , and the resident was agreeable. A nursing note, dated February 16, 2025, at 11:35 a.m., revealed that Resident 13 complained of not feeling good and was observed to be shivering while lying in bed. She was alert and oriented to herself, but a cognitive decline was noted. The physician was notified and an order was received to transfer the resident to the emergency room and the resident was agreeable. There was no documented evidence that a written notice of Resident 13's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer to the hospital on February 16, 2025. Interview with the Nursing Home Administrator on February 26, 2025, at 9:10 a.m. confirmed that there was no documented evidence that a written notice of Resident 2's or 13's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer to the hospital. 28 Pa. Code 201.14(a) Responsibility of Licensee.

Based on observations and staff interviews, it was determined that the facility failed to provide a separately-locked, permanently-affixed compartment in the refrigerator for the storage of controlled drugs in the medication room at [NAME] House. Findings include: Observations in the facility's medication room refrigerator at [NAME] House on March 13, 2024, at 8:40 a.m. revealed two multi-dose bottles of Ativan (a medication used to treat anxiety that is tightly controlled because it may be abused or cause addiction) on the top shelf in the refrigerator. The refrigerator did not contain a locked compartment that was affixed to the inside of the refrigerator to secure the Ativan. Interview with Registered Nurse 1 on March 13, 2024, at 8:43 a.m. revealed that she was not aware that there was supposed to be a locked compartment affixed to the inside of refrigerator. Interview with the Director of Nursing on March 13, 2024, at 12:05 p.m. confirmed that the refrigerator should have contained a locked compartment affixed to the inside of the refrigerator to secure controlled substances and it did not. 28 Pa. Code 211.9(a)(1) Pharmacy Services.

Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that staff reported physical abuse in a timely manner, which allowed the staff member to return to the resident to be mentally abused for one of five residents reviewed (Resident 2) putting all of the residents in danger of being abused, resulting in Immediate Jeopardy to their physical and mental safety. This deficiency was cited as past non-compliance. Findings include: The facility's abuse policy, dated April 13, 2023, revealed that it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Training topics will include prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property. Recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown cause. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to responding immediately to protect the alleged victim and integrity of the investigation. An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated November 16, 2023, revealed that the resident was understood, understands, and had a diagnosis which included Parkinson's disease, anxiety, and depression. A statement completed by Licensed Practical Nurse 1, dated January 29, 2024, at 2:00 p.m., revealed that on January 29, 2024, at 7:30 a.m. she was assisting Nurse Aide 2 with Resident 2. They were getting the resident out of bed by Hoyer lift (a mobile floor lift system that rolls on wheels and is intended to help lift, suspend, and transfer a medically-dependent person) and placing her in her wheelchair for breakfast. After the resident was safely placed in her wheelchair, Nurse Aide 2 put the footrests on the wheelchair and attempted to place the resident's feet onto the footrests. The resident then removed her feet, and in response to Nurse Aide 2 grabbed hold of the resident's ankles to place them back onto the footrests. Every time Nurse Aide 2 grabbed hold of the resident's ankles, the resident would holler out and place her feet back on the ground. Based on these actions the nurse knew that the resident did not want her feet on the footrests. Nurse Aide 2 attempted to place her feet on the footrests again. When Nurse Aide 2 was bent over grabbing hold of the resident's ankles again, the resident hit Nurse Aide 2 with her open hand on Nurse Aide 2's back. Nurse Aide 2 then stood up straight and opened handed slapped the resident on her left hand and then told the resident, You are being an ass. Nurse Aide 2 then took the Hoyer lift out of the room and Licensed Practical Nurse 1 stayed in the room with the resident. Nurse Aide 2 returned back to the room to comb the resident's hair and stated to the resident, I hope that did hurt, then walked back out of the room. There was no evidence to indicate that Resident 2's initial physical and verbal abuse (that included grabbing her ankles and repeatedly placing them back on the footrests of the wheelchair, slapping the resident or calling her an asshole) by Nurse Aide 2 was immediately reported when it happened. A statement completed by the Nursing Home Administrator (NHA), dated February 9, 2024, revealed that on January 29, 2024, she reviewed with Licensed Practical Nurse 1 her written statement regarding the incident with Resident 2. She reviewed with Licensed Practical Nurse 1 that Nurse Aide 2 should have been immediately sent off the unit to the staff lounge until the Director of Nursing or NHA could speak with her. The NHA also stated that Nurse Aide 2 should not have been allowed to come back into the resident's room to comb her hair. Following the incident on January 29, 2024, the facility's corrective actions included: Nurse Aide 2 was suspended of her duties, and after the investigation her employment with the facility was terminated. An audit of residents was performed. Licensed Practical Nurse 1 was re-educated regarding abuse. Re-education regarding abuse to staff was started. Daily random audits of residents were being completed. On February 15, 2024, at 5:10 p.m. the Nursing Home Administrator and Director of Nursing were given the required Immediate Jeopardy Template due to the failure of the facility to ensure that Licensed Practical Nurse 1 immediately reported the witnessed abuse of Resident 2 by Nurse Aide 2, and to protect the resident by allowing Nurse Aide 2 to return to the resident's room. On February 15, 2024, at 8:00 p.m. the facility submitted an immediate action plan that included: The nurse aide was suspended at the time of the reported abuse and is no longer employed at the facility. An in-house audit was performed on residents at the time of the incident, and assessments were completed along with interviews to confirm no other residents were identified. In-house re-education was provided to staff on abuse and reporting of abuse. The facility will not allow an employee to work unless education has been completed prior to returning to work. Daily random audits of care and interviews continue to ensure that no residents have been affected. The audits are going to be reviewed at Quality Assurance Performance Improvement (QAPI) meetings. Facility staff were interviewed on February 16, 2024, and were knowledgeable of the facility's policy on abuse. The facility alleged compliance on January 31, 2024. The Immediate Jeopardy was lifted on February 16, 2024, at 12:03 p.m. when it was confirmed that the corrective action plans developed on January 29, 2024, were completed by January 31, 2024, and that Resident 2 and any other current residents were not physically/mentally abused since January 31, 2024. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies, clinical records, and personnel files, as well as staff interviews, it was determined that the facility failed to properly address a resident's behavior of repeatedly taking her feet off the wheelchair footrests and placing them on the ground for one of five residents reviewed (Resident 2), resulting in Immediate Jeopardy when the nurse aide continued to grab hold of the resident's ankles, causing her to yell out and place her feet back on the ground, which resulted in the resident hitting the nurse aide while the nurse aide was bent over to once again grab the resident's ankles to place the her feet back on the wheelchair footrests. In response, the nurse aide slapped the resident's hand and called the resident an asshole. Findings include: The facility's policy regarding behaviors, dated April 13, 2023, revealed that facility staff will attempt to implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions, to help meet behavioral health needs and may include, but are not limited to offering hydration and nutrition; exercise; pain relief; individualizing sleep and dining routines; considerations for restroom use, incontinence; adjusting the environment to be more individually preferred or homelike; consistent staffing to optimize familiarity; supporting the resident through meaningful activities that match his/her individualized abilities, interests and needs; assisting the resident with outdoors activity weather permitting; providing access to pets or animals for the resident who enjoys pets; assisting the resident to participate in activities that support their spiritual needs; focusing the resident on activities that decrease stress and increase awareness of actual surroundings, such as familiar activities; offering verbal reassurance, especially in terms of keeping the resident safe; and acknowledging that the resident's experience is real to her/him; utilizing techniques such as music, art, electronics/computer technology systems, reminiscing, and providing redirection. A review of the personnel file for Nurse Aide 2 revealed that she was hired by the facility on October 13, 2003, received customer service training on January 23, 2023; received elder abuse training on May 2, 2023; received resident rights training on April 5, 2023; received hand-and-hand dementia module 1 training on June 5, 2023; hand-and-hand dementia module 2 training on July 5, 2023; received abuse, prevention, reporting and elder justice act training on August 29, 2023; and received behavioral health training on August 29, 2023. On December 10, 2017, she received disciplinary action regarding concerns that they had received multiple complaints about her poor attitude, being rude to other nurse aides, and speaking harshly and disrespectfully to residents. An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated November 16, 2023, revealed that the resident was understood and could understand others, and had diagnoses that included Parkinson's disease, anxiety, and depression. A nursing note for Resident 2, dated January 18, 2024, revealed that the nurse and the nurse aide attempted to get the resident into the bath multiple times. The resident refused and became combative and kept stating she will tomorrow, or she will let them know when she wants a shower. A nursing note for Resident 2, dated January 21, 2024, revealed that the resident was hitting, pinching, and cursing at staff with morning care. Even with attempts of calming talk and redirecting, she was attempting to get out of bed by herself and did not want staff to assist her. A statement completed by Licensed Practical Nurse 1, dated January 29, 2024, at 2:00 p.m., revealed that on January 29, 2024, at 7:30 a.m. she was assisting Nurse Aide 2 with Resident 2. They were getting the resident out of bed by Hoyer lift (a mobile floor lift system that rolls on wheels and is intended to help lift, suspend, and transfer a medically-dependent person) and placing her in her wheelchair for breakfast. After the resident was safely placed in her wheelchair, Nurse Aide 2 put the footrests on the wheelchair and attempted to place the resident's feet onto the footrests. The resident then removed her feet, and in response to this Nurse Aide 2 grabbed hold of the resident's ankles to place them back onto the footrests. Every time Nurse Aide 2 grabbed hold of the resident's ankles, the resident would holler out and place her feet back on the ground. Based on these actions the nurse knew that the resident did not want her feet on the footrests. Nurse Aide 2 attempted to place her feet on the footrests again. When Nurse Aide 2 was bent over grabbing hold of the resident's ankles again, the resident hit Nurse Aide 2 with her open hand on Nurse Aide 2's back. Nurse Aide 2 then stood up straight and opened handed slapped the resident on her left hand and then told the resident, You are being an ass. Nurse Aide 2 then took the Hoyer lift out of the room and the nurse stayed in the room with the resident. Nurse Aide 2 returned back to the room to comb the resident's hair and stated to the resident, I hope that did hurt, then walked back out of the room. A statement completed by Nurse Aide 2, undated, revealed that while doing care on Resident 2, she started hitting me. I told her to stop it. I put my hand in front of hers to stop her from hitting me. She then started to yell at me. She was yelling and hitting me while the nurse was just standing there. The resident then started kicking and would not keep her feet on the wheelchair footrests. There was no documented evidence in Resident 2's clinical record to indicate that Nurse Aide 2 attempted a different approach with the resident or other interventions to prevent her behavior from escalating to the point of hitting Nurse Aide 2. On February 15, 2024, at 5:10 p.m. the Nursing Home Administrator and Director of Nursing were given the Immediate Jeopardy Template due to the failure of the facility to properly address a resident's behavior of repeatedly taking her feet off the wheelchair footrests and placing them on the ground. The nurse aide continued to grab hold of the resident's ankles, causing her to yell out and place her feet back on the ground, which resulted in the resident hitting the nurse aide while the nurse aide was bent over to once again grab her ankles to place the her feet back on the wheelchair footrests. In response, the nurse aide slapped the resident's hand and called the resident an asshole. On February 15, 2024, at 9:31 p.m. the facility submitted an immediate action plan that included: The nurse aide was suspended at the time of the reported abuse and is no longer employed at the facility. Licensed Practical Nurse 1 was re-educated regarding abuse. Resident 2's care plan was updated to identify the resident's behaviors. Care plans will be established for residents that exhibit behaviors with individualized interventions. In-house re-education was provided to staff on the facility's behavioral policy and how to manage behaviors. The facility will not allow an employee to work unless education has been completed prior to returning to work. Daily random audits of care and interviews continue to ensure that no residents have been affected. The audits are going to be reviewed at Quality Assurance Performance Improvement (QAPI) meetings. Interview with the Nursing Home Administrator on February 16, 2024, at 9:35 a.m. revealed that they felt Resident 2 did not have any behaviors for them to address at the time of the incident. The facility acknowledged compliance on February 16, 2024. The Immediate Jeopardy was lifted on February 16, 2024, at 12:03 p.m. when it was confirmed that the corrective action plans developed on February 15, 2024, were implemented. It was confirmed that Resident 2 and any other current residents did not exhibit any behaviors. The majority of staff were educated, and a plan for remaining staff to receive the education prior to the start of their next work shift was developed and implemented. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from physical and mental abuse for one of five residents reviewed (Resident 2), resulting in Immediate Jeopardy to the resident's physical, mental health, and safety. This deficiency was cited as past non-compliance. Findings include: The facility's abuse policy, dated April 13, 2023, revealed that it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated November 16, 2023, revealed that the resident was understood, could understand, and had diagnoses that included Parkinson's disease, anxiety, and depression. A statement completed by Licensed Practical Nurse 1, dated January 29, 2024, at 2:00 p.m., revealed that on January 29, 2024, at 7:30 a.m. she was assisting Nurse Aide 2 with Resident 2. They were getting the resident out of bed by Hoyer lift (a mobile floor lift system that rolls on wheels and is intended to help lift, suspend, and transfer a medically-dependent person) and placing her in her wheelchair for breakfast. After the resident was safely placed in her wheelchair, Nurse Aide 2 put the footrests on the wheelchair and attempted to place the resident's feet onto the footrests. The resident then removed her feet, and in response to this Nurse Aide 2 grabbed hold of the resident's ankles to place them back onto the footrests. Every time Nurse Aide 2 grabbed hold of the resident's ankles, the resident would holler out and place her feet back on the ground. Based on these actions the nurse knew that the resident did not want her feet on the footrests. Nurse Aide 2 attempted to place her feet on the footrests again. When Nurse Aide 2 was bent over grabbing hold of the resident's ankles again, the resident hit Nurse Aide 2 with her open hand on Nurse Aide 2's back. Nurse Aide 2 then stood up straight and opened handed slapped the resident on her left hand and then told the resident, You are being an ass. Nurse Aide 2 then took the Hoyer lift out of the room and Licensed Practical Nurse 1 stayed in the room with the resident. Nurse Aide 2 returned back to the room to comb the resident's hair and stated to the resident, I hope that did hurt, then walked back out of the room. An undated statement completed by Student Practical Nurse 3 indicated that on the morning of January 29, 2024, the student nurse heard Nurse Aide 2 raise her voice with a resident. Student Practical Nurse 3 was sitting in the nurses' station working on school paperwork when Licensed Practical Nurse 1 went to Resident 2's room to assist Nurse Aide 2 with the Hoyer lift. Shortly after she left, Student Practical Nurse 3 heard Nurse Aide 2 raise her voice to Resident 2. Student Practical Nurse 3 did not hear all that was said but remembered her saying this is ridiculous, do not hit me, and some comment about Resident 2 sliding in her wheelchair. Student Practical Nurse 3 was able to hear her comments clearly from the nurses' station. A social worker's interview with Resident 2, dated January 29, 2024, revealed that she spoke with Resident 2 regarding how she was treated that morning. The resident advised her that her caregiver this morning chose clothes that she did not want. The caregiver, whose name she could not remember, was cussing at her and even hit her, indicating her left wrist area, and stated fresh this morning. Resident 2 said, I hit her back. A statement completed by the Director of Nursing revealed that on January 29, 2024, at 7:45 a.m., upon arriving on the [NAME] House unit, she was updated that Licensed Practical Nurse 1 had witnessed an occurrence between Nurse Aide 2 and Resident 2. Licensed Practical Nurse 1 reported that while performing care for the resident Nurse Aide 2 open handed slapped the resident's left hand and she called the resident an ass. Nurse Aide 2 also said to the resident, I hope that hurt. Interview with Licensed Practical Nurse 1 on February 15, 2024, at 2:55 p.m. revealed that she went in to help Nurse Aide 2 with the Hoyer lift because Resident 2 was a Hoyer lift. She indicated that when she went into the room, she could tell that the resident was shaken up. They got the resident into her wheelchair and Nurse Aide 2 was insistent to place the resident's feet on the wheelchair footrests. She knew that the resident did not want her feet on the footrests. Nurse Aide 2 was bent over, and the resident slapped her on the back. Nurse Aide 2 then stood up and slapped the resident and called her an asshole. Nurse Aide 2 then took the Hoyer lift out of the room. She then returned to comb the resident's hair and stated, I hope that did hurt. She indicated that she remembered saying to Nurse Aide 2 that she can transfer herself and thought to herself that the resident slapped Nurse Aide 2 because it must have hurt. She indicated that she and the resident were near the resident's bed when Nurse Aide 2 came back in by the bathroom door and stated I hope that did hurt, and after making the comment she turned around leaving the resident's room. Following the incident on January 29, 2024, the facility's corrective actions included: Nurse Aide 2 was suspended of her duties, and after the investigation her employment with the facility was terminated. An audit of residents was performed. Licensed Practical Nurse 1 was re-educated regarding abuse. Re-education regarding abuse to staff was started. Daily random audits of residents were being completed. On February 15, 2024, at 5:10 p.m. the Nursing Home Administrator and Director of Nursing were given the required Immediate Jeopardy Template and informed that the physical/mental health and safety of Resident 2 had been placed in Immediate Jeopardy due to the failure of the facility to ensure that Resident 2 was not subjected to physical/mental abuse by Nurse Aide 2, who physically/mentally abused the resident. On February 15, 2024, at 8:00 p.m. the facility submitted an immediate action plan that included: The nurse aide was suspended at the time of the reported abuse and is no longer employed at the facility. An in-house audit was performed on residents at the time of the incident, and assessments were completed along with interviews to confirm no other residents were identified. In-house re-education was provided to staff on abuse and reporting of abuse. The facility will not allow an employee to work unless this education has been completed prior to returning to work. Daily random audits of care and interviews continue to ensure that no residents have been affected. The audits are going to be reviewed at Quality Assurance Performance Improvement (QAPI) meetings. Facility staff were interviewed on February 16, 2024, and were knowledgeable of the facility's policy on abuse. The facility alleged compliance on January 31, 2024. The Immediate Jeopardy was lifted on February 16, 2024, at 12:03 p.m. when it was confirmed that the corrective action plans developed on January 29, 2024, were completed by January 31, 2024, and that Resident 2 and any other current residents were not physically/mentally abused since January 31, 2024. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(j) Resident Rights.

Based on review of job descriptions and the deficiencies cited during the current survey, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to assume responsibility for effective management of the facility to ensure that the residents' environment remained free from abuse, for ensuring that staff reported abuse and protected the resident from further abuse, and for ensuring that staff properly address a resident's behavior. Findings include: The job description for the NHA, dated January 17, 2023, indicated that the primary function of this position was to provide general oversight and direction to all services provided by the Brookview Health Care Center. Maintains compliance with the Department of Health, Welfare, Medicare, and Educational regulatory requirements. Supervision and coordination of services to include overseeing budget and corporate policies and procedures related to the care of all residents. The job description for the DON, dated October 15, 2020, indicated that the primary function of this position was to organize, administrate, and supervise the total nursing service program in compliance with the regulatory process and operational guidelines, and modifies nursing care policies and/or procedures to maintain the highest practicable well-being of each resident. The deficiencies cited under the Code of Federal Regulatory Groups for Long-Term Care, 483.12 Freedom from Abuse, Neglect, and Exploitation (F600), revealed that the NHA and DON failed to fulfill their essential job duties for ensuring that the residents' environment remained free from abuse. The deficiencies cited under the Code of Federal Regulatory Groups for Long-Term Care, 483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property and 483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act (F607), revealed that the NHA and DON failed to fulfill their essential job duties for ensuring that staff timely reported abuse and allowing staff to return to the resident. The deficiencies cited under the Code of Federal Regulatory Groups for Long-Term Care, 483.40(b)(2) A resident whose assessment did not reveal or who does not have a diagnosis of a mental or psychosocial adjustment difficulty or a documented history of trauma and/or post-traumatic stress disorder does not display a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless the resident's clinical condition demonstrates that development of such a pattern was unavoidable (F743), revealed that the NHA and DON failed to fulfill their essential job duties for ensuring that staff properly address a resident's behavior. Refer to F600, F607 and F743. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address resident care needs for one of five residents reviewed (Resident 2). Findings include: The facility's policy regarding behaviors, dated April 13, 2023, revealed that facility staff will attempt to implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions. An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated November 16, 2023, revealed that the resident was understood, understands, and had a diagnosis which included Parkinson's disease, anxiety, and depression. A nursing note for Resident 2, dated January 18, 2024, revealed that the nurse and the nurse aide attempted to get the resident into the bath multiple times. The resident refused and became combative and kept stating she will tomorrow, or she will let them know when she wants a shower. A nursing note for Resident 2, dated January 21, 2024, revealed that the resident was hitting, pinching, and cursing at staff with morning care. Even with attempts of calming talk and redirecting, she was attempting to get out of bed by herself and did not want staff to assist her. A statement completed by Licensed Practical Nurse 1, dated January 29, 2024, at 2:00 p.m., revealed that on January 29, 2024, at 7:30 a.m. she was assisting Nurse Aide 2 with Resident 2. They were getting the resident out of bed by Hoyer lift (a mobile floor lift system that rolls on wheels and is intended to help lift, suspend, and transfer a medically-dependent person) and placing her in her wheelchair for breakfast. After the resident was safely placed in her wheelchair, Nurse Aide 2 put the footrests on the wheelchair and attempted to place the resident's feet onto the footrests. The resident then removed her feet and in response to this Nurse Aide 2 grabbed hold of the resident's ankles to place them back onto the footrests. Every time Nurse Aide 2 continued to grab hold of the resident's ankles, the resident would holler out and place her feet back on the ground. Based on these actions the nurse knew that the resident did not want her feet on the footrests. Nurse Aide 2 attempted to place her feet on the footrests again. When Nurse Aide 2 was bent over grabbing hold of the resident's ankles again, the resident hit Nurse Aide 2 with her open hand on Nurse Aide 2's back. A statement completed by Nurse Aide 2, undated, (referring to the incident of January 29, 2024, at 7:30 a.m.) revealed that while doing care on Resident 2, she started hitting me. I told her to stop it. I put my hand in front of hers to stop her from hitting me. She then started to yell at me. She was yelling and hitting me while the nurse was just standing there. The resident then started kicking and would not keep her feet on the wheelchair footrests. There was no documented evidence that a comprehensive care plan that included specific and individualized interventions was developed for Resident 2 regarding her behaviors until February 15, 2024. Interview with the Nursing Home Administrator on February 16, 2024, at 9:35 a.m. revealed that they felt Resident 2 did not have any behaviors, so a care plan was not developed regarding behaviors until February 15, 2024. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a baseline care plan included instructions regarding behaviors and the use of psychotropic medications for one of five residents reviewed (Resident 5) who was admitted after February 9, 2024. Findings include: A nursing note, dated February 9, 2024, at 11:14 a.m., revealed that the resident was admitted to the facility on this date. Physician's orders, dated February 9, 2024, included orders for 12.5 mg of Seroquel in the morning and 25 mg of Seroquel(antipsychotic) at bedtime for dementia with behaviors, 0.25 milliliters (mL) of lorazepam (anti-anxiety) three times a day for anxiety, and 10 mg of escitalopram (anti-depressant) in the morning for major depression. A Certified Registered Nurse Practitioner (CRNP, a registered nurse who has advanced education and clinical training in a health care specialty area) note, dated February 9, 2024, revealed that the resident was agitated and anxious, refused to have her dressing changed, refused to have a skin evaluation, and refused her medications. New orders were received for 2.5 milligrams (mg) of Haldol (antipsychotic) one time, 0.5 mg of Ativan (anti-psychotic) three times a day for three days, and she was to continue her as-needed Ativan and 12.5 mg of Seroquel in the morning. A nursing note, dated February 9, 2024, at 2:21 p.m., revealed that the resident's daughter informed the facility that Resident 5 had behaviors of hitting, spitting, kicking, and throwing objects if she was mad and did not want anything or did not like something. She refused to allow the nurse to assist her with the removal of her coat and accepted sips of water and gingerale at lunch time, then threw her cup of gingerale. She was offered a cup of hot tea, and the resident picked up the cup and threw it at the nurse. Staff attempted to do her admission assessment and allowed staff to assess her feet and left arm, but then she began to hit, kick and spit at the nurse, and was unable to be redirected even with the daughter's assistance. Nursing notes for Resident 5, dated February 10, at 3:54 p.m., revealed that the resident was combative with morning medications, and on February 11, 2024, at 11:06 a.m. the resident was highly combative and hitting and spitting at staff. A baseline care plan for Resident 5, dated February 9, 2024, did not include instructions regarding Resident 5's behaviors or use of psychotropic medications. Interview with the Nursing Home Administrator on February 16, 2024, at 12:44 p.m. confirmed that Resident 5 had behaviors and used psychotropic medications, and the resident's baseline care plan should have included this information. 28 Pa. Code 211.12(d)(1) Nursing Services.

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's dignity was maintained for two of 25 residents reviewed (Residents 10, 22). Findings include: The facility's policy regarding call lights indicated that staff members who are alerted of an activated call light are responsible for responding. An annual Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 10, dated March 14, 2023, revealed that the resident was alert and oriented; able to make his needs known; required extensive assistance from staff for daily care needs including toileting, hygiene, and transfers; and was occasionally incontinent of bladder. Interview with Resident 10 on April 17, 2023, at 11:00 a.m. revealed that that he had to wait up to 45 minutes for staff to respond to his call bell. A call bell log for Resident 10, dated March 20 through April 18, 2023, revealed that it took staff 27 to 44 minutes to respond to the resident's call bell. A quarterly MDS for Resident 22, dated February 17, 2023, revealed that the resident was alert and oriented; able to make her needs known; required extensive assistance from staff for daily care needs including toileting, hygiene, and transfers; and was occasionally incontinent of bladder. Interview with Resident 22 on April 17, 2023, at 10:15 a.m. revealed that she had to wait up to an hour or longer for staff to respond to her call bell, which had caused her to be incontinent. A call bell log for Resident 22, dated March 14 through April 18, 2023, revealed that it took staff 22 to 65 minutes to respond to the resident's call bell. Interview with the Director of Nursing and Nursing Home Administrator on April 19, 2023, at 11:51 a.m. revealed that the call bell wait times were excessive and not acceptable. The Director of Nursing stated that she believed 10-15 minutes would be an appropriate wait time. 28 Pa. Code 201.29(j) Resident rights.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was stored in accordance with professional standards for food service safety. Findings include: The facility's policy regarding food handling, dated September 2022, revealed that upon completion of meal service, all suitable prepared foods are covered, labeled, and dated with a prepared date, and a use-by-date. The facility's current policy regarding date marking for food safety revealed that the food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The discard day or date may not exceed the manufacturer's use-by date, or four days, which ever is the earliest. The date of opening or preparation counts as day one. The facility's policy regarding the storage of refrigerated and frozen foods, dated September 2022, revealed that ham slices could be stored in the freezer for a maximum period of up to two months. Observations of a countertop single door freezer in the Martin and [NAME] House Pantry on April 17, 2023, at 11:40 a.m. revealed that there was a metal tray with nine meat patties covered with Saran wrap that was not labeled with the name of the product or with a date. There was a plastic bag containing chicken tenders and a plastic bag containing French fries that were opened and not labeled with the date they were opened. Interview with Lead Homemaker 1 on April 17, 2023, at 11:56 a.m. confirmed that the above items should have been labeled with the date they were opened and the name of the product. Observations of an under-the-counter single door freezer in the [NAME] Pantry on April 17, 2023, at 12:08 p.m. revealed a plastic bag that contained three pieces of pureed (cooked food that has been ground, pressed, blended, or sieved to the consistency of a creamy paste or liquid) ham, dated November 24, 2022, and a plastic bag containing three chicken thighs that were not labeled with the date they were opened. Interview with Homemaker 2 on April 17, 2023, at 12:15 p.m. revealed that she was not sure how long the pureed ham could be stored before it needed to be removed and confirmed that the chicken thighs should have been labeled with the date they were opened. Interview with the Nursing Home Administrator on April 19, 2023, at 10:40 a.m. revealed that she spoke with the Culinary Director, and he confirmed that the undated items should have been dated with the date they were opened, the meat patties should have been labeled with the product name, and the pureed ham, dated November 24, 2022, should have been removed. 28 Pa. Code 211.6(f) Dietary services.

Based on review of Pennsylvania's Nursing Practice Act, facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to clarify questionable physician's orders for one of 25 residents reviewed (Resident 20). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 20, dated March 13, 2023, revealed that the resident was alert and oriented, required limited assistance for daily care needs, and had diagnoses that included hypertension (high blood pressure). Physician's orders for Resident 20, dated June 8, 2022, included an order for the resident to receive 10 milligrams (mg) of isosorbide (used to treat high blood pressure) twice a day as needed for a systolic blood pressure (pressure when heart is pumping) greater than 200 mmHg (millimeters/mercury) for hypertension. A physician's order, dated June 20, 2022, included an order to obtain the resident's blood pressure daily every day shift and to give isosorbide for a systolic blood pressure greater than 200 mmHg. However, there was no documented evidence when the resident's blood pressure was to be monitored for the possible administration of the as-needed isosorbide twice a day. Resident 20's Treatment Administration Record (TAR) for March and April 2023 indicated that the resident's blood pressure was taken daily during the day shift, but the resident's blood pressure log revealed that there was no consistency as to when the resident's blood pressure was obtained during the remainder of the day for the possible administration of the as-needed isosorbide twice a day. Interview with the Director of Nursing on April 19, 2023, at 12:48 p.m. confirmed that the physician's order should have been clarified to determine what times the resident's blood pressure was to be monitored twice a day. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of guidance from the Centers for Disease Control (CDC), facility documents, and policies, as well as observations and staff interviews, it was determined that the facility failed to follow CDC guidelines to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic for one of three employees reviewed (Employee 1), failed to ensure that proper hand washing techniques were used while providing incontinent care, and failed to ensure proper cleaning of a resident's pressure cushion after being soiled for one of 24 residents reviewed (Resident 6). Findings include: Guidance from the CDC (the national health protection agency) regarding Evaluating and Managing Healthcare Personnel (HCP), dated June 25, 2020, recommended that all HCP be screened at the beginning of their shift for fever and symptoms of COVID-19 (an infectious disease caused by a virus that can cause fever, cough, fatigue and/or breathing problems). They were to actively have their temperature taken and document the absence of symptoms consistent with COVID-19. If they were ill, they were to keep their cloth face covering or facemask on and leave the workplace. Guidance from the CDC regarding Symptoms of Coronavirus, dated May 13, 2020, indicated that people with COVID-19 have a wide range of symptoms reportedly ranging from mild symptoms to severe illness, and symptoms could appear 2-14 days after exposure to the virus. People with the following symptoms could have COVID-19: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea. Pennsylvania Health Alert Network (PA-HAN) - 609 - regarding Core Infection Prevention and Control Measures for Long-term Care Facilities, dated December 1, 2021, revealed that to evaluate and manage healthcare personnel (HCP), options could include (but are not limited to): Individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, HCP report absence of fever and symptoms of COVID-19, absence of a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Fever in this setting is defined as a measured temperature = 100.0 degrees Fahrenheit (F) or a report of subjective fever (i.e., feeling feverish). People might not notice symptoms of fever at this level, so a measured temperature should be used if the HCP feels well. HCP who reports symptoms should be excluded from work and should notify occupational health services to arrange for further evaluation. In addition, asymptomatic HCP who report close contact with others with [CONDITION(S)]-CoV-2 infection might need to be excluded from work. If HCP develops a fever (Temperature =100.0 degrees F) or symptoms consistent with COVID-19 while at work, they should inform their supervisor and leave the workplace. The facility's policy regarding Coronavirus Surveillance, dated April 21, 2022, revealed that the facility shall implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for the illness. Heightened surveillance activities will be implemented to limit the transmission of COVID-19. These include, but are not limited to: Screening visitors, team members, and guests. Screening for visitors and team members: Signs or symptoms of a respiratory infection, such as fever, cough, shortness of breath, or sore throat. In the last 10 days, has had contact with someone with a confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Residing in a community where community-based spread of COVID-19 is occurring. Team members who have signs and symptoms of respiratory infection shall not report to work. The facility's policy regarding education, monitoring, and screening of staff, dated April 21, 2022, revealed that staff have been provided online education regarding COVID-19 (e.g symptoms, transmission, screening criteria, and work exclusions). All staff are screened at beginning and end of shift for fever and signs/symptoms of illness. Instructions for the facility's screening log, undated, revealed that it is a critical line of defense to prevent COVID-19 from entering our community. As such, it is imperative that this be an active screening process for all team members in skilled nursing and personal care environments. The screening site must be staffed by a team member who understands the process and has the authority and knowledge to appropriately direct a team member who triggers a response in the screening tool. A Point of Care COVID-19 test for Employee 1, dated February 13, 2022, revealed that she complained of runny nose, stuffy nose, and sore throat. Employee 1 was tested at 1:20 p.m. and the result of her test at 1:35 p.m. was positive for COVID-19. Facility Timesheets/Time Card for Employee 1, dated February 13, 2022, revealed that Employee 1 worked a portion of the first shift (6:00 a.m. to 1:45 p.m.). There was no documented evidence that Employee 1 completed the facility's screening process prior to the start of her shift for the date listed. Interview with the Nursing Home Administrator on May 10, 2022, at 3:30 p.m. confirmed that there was no documented evidence that Employee 1 performed the facility's screening process on the date listed above and that she should have been screened in prior to her shift as per facility policy. The facility's policy for handwashing, dated April 21, 2022, indicated that during handwashing staff are to wash their hands, rinse with water, dry thoroughly with a single-use towel, and then turn off the faucet with a clean towel. The facility's policy for cleaning and disinfecting of resident care equipment, dated April 21, 2022, indicated that resident care equipment would be cleaned and disinfected in accordance with current CDC recommendation. Reusable single-resident items are items to be used multiple times, but for one resident only. Direct care staff are responsible for cleaning single-resident use equipment when visibly soiled. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated February 17, 2022, indicated that she was confused and required extensive assistance for bed mobility and hygiene, and was always incontinent of bowel and bladder. Observations of Resident 6 during a transfer and incontinent care, on May 9, 2022, at 11:09 a.m. revealed that Licensed Practical Nurse 3 and Nurse Aide 4 transferred the resident to bed with the use of a mechanical lift. On the seat of her specialty wheelchair there was a blue cushion that was visibly wet, and there was a strong urine odor noted in her room. After getting the resident into bed, Nurse Aide 4 went out of the room and brought in a new sling and indicated to Registered Nurse 2 that a new sling was needed because the current one was wet. Registered Nurse 2 used wipes to clean the resident, who was incontinent of urine and had smeared bowel movement. After providing incontinent care, Registered Nurse 2 removed her gloves, washed her hands, and then turned the faucet off with her clean hand. Nurse Aide 4 and Licensed Practical Nurse 3 proceeded to dress the resident, placed her on a new sling, and attached her to a mechanical lift for transfer. They did a front approach with the mechanical device and placed the resident above her specialty wheelchair seat. Immediately prior to lowering her onto the chair cushion, Licensed Practical Nurse 3 was asked by the surveyor if the chair pad should be cleaned before putting the resident on the cushion because it was visibly wet. Interview with Licensed Practical Nurse 3 on May 9, 2022, at 11:36 a.m. confirmed that there were wet spots on the chair cushion and that it should be cleaned prior to putting on the cushion. Interview with Registered Nurse 2 on May 9, 2022, at 11:51 a.m. confirmed that she should have used a dry paper towel to turn off the faucet. Interview with the Director of Nursing, on May 9, 2022, at 4:57 p.m. confirmed that the faucet should have been turned off with a clean paper towel, and that Resident 6's chair pad should have been cleaned after her incontinence. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on a review of policies and manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to properly label a multi-use vial after opening on one of three nursing units ([NAME]). Findings: The facility's policy for labeling of medications, dated, April 21, 2022, revealed that labels for multi-use vials must include the date that the vial was initially opened or accessed and all opened or accessed vials should be discarded within 28 days unless the manufacturer specifies differently (shorter or longer) for that opened vial. The manufacturer's instructions for [MEDICATION(S)] ([MEDICATION(S)]-solution used to test for [CONDITION(S)] infection), undated, indicated that the 1.0 milliliter (ml) vial contained ten (0.1 ml) tests and that if the vial was in use for more than 30 days it should be discarded due to the possible oxidation (combination of a substance with oxygen) and degradation (becomes less useful), which may effect the potency. Observations of the medication refrigerator on the [NAME] nursing unit on May 10, 2022, at 7:39 a.m. revealed an opened and undated vial of [MEDICATION(S)] solution. Interview with Registered Nurse 2 on May 10, 2022, at 7:43 a.m. confirmed that the [MEDICATION(S)] vial was not dated when it was opened and that it should have been.

Based on a review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that preventive pressure ulcer interventions were in place for one of 24 residents reviewed (Resident 25). Findings include: The facility's policy for pressure ulcer prevention, dated April 21, 2022, indicated that the facility would implement interventions for all residents who are assessed as at risk or have a pressure injury present. Interventions will be documented in the care plan and communicated to all relevant staff. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated February 25, 2022, indicated that she was confused, could usually understand and be understood, had no behaviors of care rejection, required extensive assist of two for bed mobility, total assist of two for transfers, was non-ambulatory, had impaired range of motion on one side, and was at risk for pressure ulcers. A wound assessment for Resident 25, dated December 14, 2021, indicated that she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The current care plan for Resident 25, dated December 22, 2021, indicated that the resident was to wear blue booties at all times except for care. Observations of Resident 25 on May 9, 2022, at 12:09 p.m. and March 11, 2022, at 8:24 a.m. revealed that she was in her broda chair (specialty chair) with nonskid socks on and the blue boots were not in use. Interview with Nurse Aide 1 on May 11, 2022, at 8:44 a.m. indicated that her blue boots were only to be on when she was in bed. Interview with the Registered Nurse Assessment Coordinator (RNAC) 5, on May 11, 2022, at 8:52 a.m. and 9:29 a.m. confirmed that the blue boots were to be on Resident 25 at all times per her care plan and also confirmed that there was no documented evidence to indicate that she had been wearing them at all times each day as care planned. 28 Pa. Code 211.12(d)(5) Nursing services.