Every finding on record at Cedar Crest Post Acute

Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to ensure that physician prescribed medications were administered as ordered to one of four sampled residents. (Resident CR 1) Findings include:Resident CR 1 was admitted to the facility with diagnoses that included end stage kidney disease and emphysema. Facility provided documentation revealed that on April 16, 2026, the resident was administered medications to treat hypertension (metoprolol and amlodipine), a medication to treat attention deficit disorder (Ritalin), a medication to prevent blood clots (Eliquis), and a medication to reduce stomach acid (Protonix). Review of the resident's physician orders for April 2026 revealed that the medications were not ordered for Resident CR 1.In an interview on April 30, 2026, at 10:30 a.m., the Director of Nursing confirmed that Resident CR 1 was administered medications not prescribed by the physician. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assess a resident's capability to self-administer medications for two of 32 sampled residents. (Residents 65 and 170)Findings include: Review of the facility policy entitled, Administering Medications, last reviewed April 30, 2025, revealed that a resident may only self-administer their own medications if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Review of the facility policy entitled, Self-Administration of Medications, last reviewed April 30, 2025, revealed that as part of the evaluation, the interdisciplinary team assessed each resident's cognitive and physical abilities to determine whether self-administering medications was safe and clinically appropriate for the resident, if it was deemed safe and appropriate for a resident to self-administer medications, that was documented in the medical record and the care plan. Clinical record review revealed that Resident 65 had diagnoses that included heart failure, diabetes, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated October 30, 2025, revealed that Resident 65's cognition was intact. There was no documented evidence that Resident 65 had been assessed for the ability to self-administer medication. Observation on November 24, 2025, between 11:35 a.m. and 11:57 a.m., revealed a medicine cup containing 12 unidentified pills unsecured on the bedside table in Resident 65's room. An interview with Resident 65 at 11:35 a.m., revealed that the pills were her morning medications that the nurse left on her table. In an interview with RN 1 on November 25, 2025, at 10:33 a.m., RN 1 confirmed she left the medications on the resident's bedside table. Clinical record review revealed that Resident 170 had diagnoses that included frontotemporal neurocognitive disorder. Review of the MDS, dated [DATE], revealed that Resident 170's cognition was intact. There was no documented evidence that Resident 65 had been assessed for the ability to self-administer medication. Observations on November 25, 2025, between 8:05 a.m. and 8:20 a.m. revealed a medicine cup containing seven unidentified pills in Resident 65's room. During that time Resident 170 stated that another nurse brought them to him, but he could not remember when. An interview with LPN 1 at 8:20 a.m., confirmed they were given to the resident during the 6:00 a.m. medication pass. In an interview on November 26, 2025, at 10:17 a.m., the Director of Nursing confirmed that Residents 65 and 170 were not assessed or approved to self-administer the medications as per the facility policy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were free from potential chemical restraints for one of five sampled residents who were ordered psychotropic medications. (Resident 93) Findings include: Clinical record review revealed that Resident 93 had a diagnoses that included anxiety and psychotic disorder with hallucinations. On August 27, 2025, a physician ordered staff to administer an anti-anxiety medication, (lorazepam), every 24 hours as needed for anxiety and sleep. There was no date in the order that indicated when staff were to stop administering the as needed medication. Review of Resident 93's Medication Administration Record revealed staff had administered the lorazepam two times in October 2025, and three times in November 2025. On October 14, 2025, a physician ordered staff to administer an anti-anxiety medication (lorazepam), every 24 hours as needed for anxiety and agitation, in addition to the August 27, 2025 as needed anti-anxiety medication order. There was no date in the order that indicated when staff were to stop administering the as needed anti-anxiety medication. Review of Resident 93's Medication Administration Record revealed staff had administered the lorazepam one time in October 2025, and five times in November 2025. There was no documented evidence that the physician had re-evaluated continued use beyond 14 days of the as needed anti-anxiety medication for the second as needed order. Staff had continued to administer both as needed anti-anxiety medications. In an interview on November 26, 2025, at 8:17 a.m., the Director of Nursing stated that there had been no date added to the orders that indicated when staff were to stop administering the as needed anti-anxiety medication. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's status for one of 32 sampled residents. (Resident 11)Findings include: Clinical record review revealed that Resident 11 had diagnoses that included stroke, nontraumatic intracerebral hemorrhage (bleeding inside the brain), unspecified sequelae of other cerebrovascular disease (long-term effects of unknown brain blood vessel problem), coronary artery disease, heart failure, hypertension, occlusion and stenosis of bilateral carotid arteries, atrial fibrillation, type two diabetes mellitus and long-term use of insulin. The MDS assessment dated September, 19, 2025, incorrectly indicated in Section N (Medications) that the resident did not receive insulin injections or an anticoagulant or antiplatelet during the previous seven days. Review of the 2025 Medication Administration Record for September revealed that staff administered an anticoagulant, antiplatelet, and an insulin injection daily during the month of September as ordered by the physician. In an interview on November 26, 2025, at 10:45 a.m., the Director of Nursing confirmed that the MDS assessment did not accurately reflect the medication status of Resident 11.

Based on a review of clinical records and staff interview, it was determined that the facility failed to implement physicians' orders for one of 32 sampled residents. (Resident 151)Findings include: Clinical record review revealed that Resident 151 had diagnoses that included hypertension (high blood pressure) and chronic systolic (congestive) heart failure. On November 3, 2024, the physician ordered that staff administer blood pressure medication (metoprolol) one time a day. The physician ordered that staff not administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 110 millimeters of mercury (mm/Hg) or if the resident's pulse was less than 60 beats per minute. Review of Resident 151's Medication Administration Records (MAR) for August, September, October, and November of 2025, revealed that staff failed to record the resident's blood pressure or pulse prior to the administration of the medication 10 times in August, seven times in September, and four times in October. Further review of the MAR revealed that the staff administered metoprolol three times in October and three times in November when the resident's SBP was below 110 mm/Hg. On December 30, 2024, the physician ordered that staff weigh Resident 151 every Monday, Wednesday, and Friday for treatment of congestive heart failure, and notify the physician if the resident gained more than two pounds (lbs.) in 24 hours or five pounds in a week. Review of Resident 151's MAR for August, September, October, and November of 2025, revealed that staff failed weigh Resident 151 on August 4 and 18, 2025, September 10, 2025, and November 24, 2025, as ordered. Review of Resident 151's MAR for August, September, October, and November 2025, revealed that Resident 151 gained more than five pounds in one week on the following occasions: August 15, 2025 - August 22, 2025 (22 lbs.)September 1, 2025 - September 8, 2025 (14.5 lbs.)October 1, 2025 - October 8, 2025 (15 lbs.)October 17, 2025 - October 24, 2025 (7 lbs.)November 17, 2025 - November 21, 2025 (5.4 lbs.)There was no documented evidence that the physician had been notified of weight changes greater than five pounds in a week. In an interview on November 26, 2025, at 10:54 a.m., the Director of Nursing confirmed that the medication was administered outside of parameters; that weights, blood pressure and pulse were not recorded, and that the physician was not notified of weight changes for Resident 151 as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to provide sufficient enteral nutrition (delivery of nutrition by a feeding tube) to maintain proper hydration and health in accordance with the physician's order for one of four sampled residents receiving nutrition by a feeding tube. (Resident 100) Findings include: Review of the facility policy entitled, Enteral Nutrition, last reviewed on April 30, 2025, revealed that a dietician monitored residents who were receiving enteral nutrition, made appropriate recommendations for interventions to enhance tolerance and nutritional adequacy, that nursing staff and providers monitored the resident for signs and symptoms of altered electrolytes, and that nursing was to confirm the orders for enteral nutrition were complete including instructions for flushing. Clinical record review revealed that Resident 100 had diagnoses that included history of a brain injury, difficulty swallowing, and had a tracheostomy for breathing. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was dependent on staff for activities of daily living and was unable to express needs or understand others. Further review of the MDS assessment revealed that the resident received more than 51 percent of nutrition through an enteral feeding tube. Clinical record review revealed that Resident 100 had bloodwork collected on November 17, 2025, that indicated the resident had a low sodium level of 131 millimoles per liter. Review of a nutrition progress note dated November 19, 2025, revealed a recommendation to decrease Resident 100's water flushes from 200 milliliters (mL) every six hours to 150 mL every six hours, or four times per day, for a total volume of 600 mL per day due to low sodium level. A physician's order dated November 19, 2025, directed staff to administer 150 mL of free water flushes every six hours. Observations on November 24, 2025, at 11:12 a.m., November 25, 2025, at 10:19 a.m., and November 26, 2025, at 11:00 a.m., revealed that the resident was in bed and was connected to the tube feeding pump that was programmed with a water flush of 150 mL every 4 hours, or six times per day, for a total volume of 900 mL per day. In an interview on November 26, 2025, at 11:05 a.m., Licensed Practical Nurse 2 (LPN 2) assigned to Resident 100 stated that they did not verify the pump was programmed based on the updated physician's order. In an interview on November 26, 2025, at 12:00 p.m., the Director of Nursing confirmed the tube feeding pump had not been programmed to match the physician's order and Resident 100 had received 300 mL per day more water than ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to maintain a medication error rate of less than five percent (%) for one of two nursing units observed during medication administration. (Second floor)Findings include: Observation of medication administration on November 25, 2025, from 8:05 a.m. to 9:00 a.m., revealed 38 medication opportunities with two medication errors that resulted in a medication administration error rate of 5.26%. Clinical record review revealed that Resident 152 had diagnoses that included asthma, chronic obstructive pulmonary disease (COPD), and corona virus 2019. A review of the physician's order dated November 20, 2025, revealed that staff was to administer three milliliters (ml) of ipratropium-albuterol inhalation solution 0.5-2.5 (3) milligram (mg)/3ml (a medication used to treat symptoms of COPD) inhaled every 12 hours and to be given prior to administering Advair Diskus Aerosol Powder 500-50 micrograms (a medication used to treat symptoms of COPD). Observation of the medication pass on November 25, 2025, at 9:00 a.m., revealed that Registered Nurse 2 (RN 2) administered the ipratropium-albuterol inhalation solution to Resident 152 after she administered the Advair Diskus, which was not in accordance with the physician's order. Clinical record review revealed that Resident 170 had diagnoses that included frontotemporal neurocognitive disorder, anemia, and high blood pressure. A review of the physician's order dated June 13, 2025, revealed that staff were to administer sennosides 8.6 mg, (a medication to treat constipation) every 12 hours. Observation of the medication pass on November 25, 2025, at 8:05 a.m., revealed that RN 2 administered Senna Plus (a tablet that contained two medications for constipation, sennosides and a stool softener, Colace) which was the incorrect medication. In an interview on November 26, 2025, at 10:20 a.m., the Director of Nursing confirmed that RN 2 administered the incorrect medication and RN 2 did not give ipratropium prior to administering the Advair Diskus. 28 Pa Code 211.12(d)(1)(5) Nursing services.

Based on observation it was determined that the facility failed to store food in a sanitary manner on one of three nursing units. (MedBridge)Findings include:Observation in the MedBridge resident refrigerator on November 25, 2025, at 9:34 a.m., revealed that the top shelf had a thick layer of crumbs and dried liquid debris. On the middle shelf there was an area of a white sticky substance and part of a plastic bag was stuck to the shelf. The area along the length of the bottom of the refrigerator under the drawers had a thick layer of a dark sticky substance. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection on one of three nursing units. (MedBridge) Findings include: Review of the facility policy entitled, Isolation- Categories of Transmission-Based Precautions, last reviewed April 30, 2025, revealed that transmission based precautions (TBPs) included contact precautions, droplet precautions, airborne precautions and required certain personal protective equipment (PPE). If a resident was identified as having a communicable disease, then TBPs were to be initiated. Staff were to post a sign on the residents' door and chart that alerted all personnel and visitors entering the room of the need for and the type of precaution. If a resident was on contact precautions, staff and visitors were expected to wear gloves and a disposable gown upon entering the room and remove before leaving the room. If a resident was on droplet precautions, masks were to be worn when entering the room, and gowns, gloves and goggles when there was risk of spraying respiratory secretions. Review of the facility policy entitled, Coronavirus Disease (COVID-19)- Identification and Management of Ill Residents, last reviewed April 30, 2025, revealed that staff who entered the room of a resident with suspected or confirmed Covid-19 infection would adhere to standard precautions and use a NIOSH- approved particulate respirator with N95 filter or higher, a gown, gloves, and eye protection such as a goggles or face shield that covers the front and sides of the face, and these residents were to remain on precautions for at least ten days. Review of the facility policy entitled, Enhanced Barrier Precautions last reviewed April 30, 2025, revealed that staff were to wear gloves and a gown prior to performing high contact resident care activities like bathing, providing hygiene, changing briefs, dressing, and changing linens. Clinical record review revealed that Resident 1 tested positive for Coronavirus disease 2019 (COVID-19) on November 16, 2025. A physician's order dated November 16, 2025, directed staff to implement droplet/contact precautions for covid every shift for ten days. Review of the care plan revealed that Resident 1 had a recently confirmed case of COVID-19. Observations on November 24, 2025, from 12:13 p.m. through 12:17 p.m., revealed licensed practical nurse (LPN) 2 entered Resident 1's room wearing gloves and a mask. Observations at that time revealed a sign was posted on the doorway of Resident 1's room indicating that droplet/contact precautions were in place and staff and visitors were to wear personal protective equipment (PPE) upon entering the room which included a gown and eye protection. LPN 2 did not wear a gown or eye protection while in the resident's room. Clinical record review revealed that Resident 20 tested positive for COVID-19 on November 18, 2025. A physician's order dated November 18, 2025, directed staff to implement isolation droplet/contact precautions for covid every shift for ten days. Review of the care plan revealed that Resident 20 had a recently confirmed case of COVID-19. Observations on November 24, 2025, from 10:32 a.m. to 10:35 a.m., revealed that LPN 2 entered Resident 20's room wearing gloves and a mask, and from 12:30 p.m. to 12:32 p.m., nurse aide (NA) 1 entered and exited Resident 20's room twice wearing gloves and a mask. Observations at that time revealed a sign was posted on the doorway of Resident 20's room indicating that droplet/contact precautions were in place and staff and visitors were to wear PPE upon entering the room which included a gown and eye protection. LPN 2 and NA 1 did not wear a gown or eye protection while in the resident's room. Clinical record review revealed that Resident 59 tested positive for COVID-19 on November 20, 2025. A physician's order dated November 20, 2025, directed staff to implement isolation droplet/contact precautions for covid every shift for ten days. Review of the care plan revealed that Resident 59 had a recently confirmed case of COVID-19. Observations on November 24, 2025, from 11:50 a.m. to 11:54 a.m., revealed LPN 2 entered Resident 59's room with a glucometer and supplies, and from 12:25 p.m. through 12:29 p.m., LPN 2 entered Resident 59's room with an insulin pen and supplies wearing a mask and gloves. Observations at that time revealed a sign was posted on the doorway of Resident 59's room indicating that droplet/contact precautions were in place and staff and visitors were to wear PPE upon entering the room which included a gown and eye protection. LPN 2 did not wear a gown or eye protection while in the resident's room. Clinical record review revealed that Resident 84 tested positive for COVID-19 on November 20, 2025. A physician's order dated November 20, 2025, directed staff to implement isolation droplet/contact precautions for covid every shift for ten days. Review of the care plan revealed that Resident 84 had a recently confirmed case of COVID-19. Observations on November 24, 2025, from 12:30 p.m. to 12:33 p.m. revealed that LPN 2 entered and exited Resident 84's room wearing a mask and gloves. Observations at that time revealed a sign was posted on the doorway of Resident 84's room indicating that droplet/contact precautions were in place and staff and visitors were to wear PPE upon entering the room which included a gown and eye protection. LPN 2 did not wear a gown or eye protection while in the resident's room. Clinical record review revealed that Resident 90 tested positive for COVID-19 on November 16, 2025. A physician's order dated November 16, 2025, directed staff to implement isolation droplet/contact precautions for covid every shift for ten days. Review of the care plan revealed that Resident 90 had a recently confirmed case of COVID-19. Observations on November 24, 2025, from 12:32 p.m. through 12:39 p.m., revealed that NA 1 entered and exited Resident 90's room wearing gloves and a mask and carrying a bag of dirty linens. Observations at that time revealed a sign was posted on the doorway of Resident 90's room indicating that droplet/contact precautions were in place and staff and visitors were to wear PPE upon entering the room which included a gown and eye protection. NA 1 did not wear a gown or eye protection while in the resident's room. Clinical record review revealed that Resident 100 had diagnoses that included history of a brain injury, difficulty swallowing, had a feeding tube, and had a tracheostomy for breathing. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident was dependent on staff for activities of daily living and was unable to express needs or understand others. Review of the care plan revealed that Resident 100 required enhanced barrier precautions related to her tracheostomy and feeding tube and staff were to wear gloves and a gown during high contact care activities. Observations of a sign posted on the doorway of Resident 100's room indicated that enhanced barrier precautions were in place and staff were to clean hands and wear PPE including a gown for high contact resident activities. Observations on November 24, 2025, at 11:48 a.m., revealed NA 1 gathered fresh linens and entered Resident 100's room wearing a mask and gloves. Resident 100 was observed in her bed at that time. At 11:55 a.m., NA 1 was observed stripping resident 100's bed and wearing a mask and gloves and Resident 100 was observed in her chair. At 12:05 p.m., NA 1 exited Resident 100's room with a bag containing soiled linens. NA 1 did not wear a gown while changing Resident 100's linens. In an interview on November 26, 2025, at 9:43 p.m., the Director of Nursing confirmed that droplet and contact precautions should have been implemented and the policies were not followed by staff. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to implement comprehensive care plan interventions to address individual resident needs as identified in the comprehensive assessment for one of seven sampled residents. (Resident 1)Findings include: Clinical record review revealed that Resident 1 had diagnoses that included chronic obstructive pulmonary disease, osteoarthritis, and osteoporosis. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident was able to communicate her needs clearly and required staff assistance for mobility. Review of the current care plan revealed that Resident 1 was at risk for falls with an intervention for staff to ensure that the resident had a reacher (an assistive tool to help retrieve objects) placed within her reach. In an interview at 1:30 p.m., on September 4, 2025, Resident 1 stated, I haven't had my reacher in a while. I would like to have it. Observation of Resident 1's room revealed that the reacher was not available to the resident. At 1:45 p.m., Licensed Practical Nurse Supervisor 1 (LPNS 1) looked in Resident 1's room and could not find the reacher. In an interview on September 4, 2025, at 1:45 p.m., LPNS 1 confirmed that the reacher for Resident 1 was a current intervention and that it was not in the resident's room for her to use. CFR 483.21(b)(1) Comprehensive Care PlansPreviously cited 10/10/24 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and resident interview, it was determined that the facility failed to accomodate the needs and maintain dignity for two of seven sampled residents. (Residents 1 and 3) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included a stroke with hemiplegia on her right dominant side, aphasia (inability to swallow), dysphagia (speech impairment), and depression. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident needed help with self care, had limitations in range of motion on one side of her upper extremities, and required maximum assistance with toileting and dressing. Further review of the MDS assessment revealed that family had relayed to the facility that it was very important for the resident to choose her own activities, clothing, and bed time. A review of the care plan revealed that the resident had a communication deficit and there was an intervention for staff to anticipate and meet her needs. In addition, the care plan revealed the resident had an activities of daily living (ADL) self care deficit. There were interventions for staff to assist her with dressing and toileting and to encourage her to use the call bell for assistance. Review of a nurse practitioner's note dated April 23, 2025, revealed that Resident 1 does try to express herself and does appear to have some understanding of questions asked. On May 3, 2025, at 10:40 a.m., 11:00 a.m., 11:15 a.m., and 11:30 a.m., observation revealed that the resident was in bed and only dressed in a hospital gown. The hospital gown was falling down in the front and was not tied or snapped in order to fully cover her upper chest. Her hair was not combed and it did not appear that she had received assistance with her hygeine care, including getting out of bed and getting dressed. During the observations, her call bell was tangled and hanging behind her night stand and out of her reach. In an interview with Resident 1 at 10:40 a.m., when asked if she had her call bell, she shook her head no and was turning her head to see if she could find it. She was not aware of where the call bell was and she did not have access to it to call staff for assistance. Further observation at 12:00 p.m., revealed that Resident 1 was dressed and seated at bed side in her wheelchair. Her hair was combed and she had been served her lunch. In an interview at that time, when asked if she felt better now that she was out of bed, dressed and had received care, she smiled and nodded yes. Clinical record review revealed that Resident 3 had diagnoses that included diabetes, fibromyalgia (chronic pain in muscles and soft tissues surrounding joints), and major depressive disorder. A review of the care plan revealed that she had an ADL self care deficit and there was an intervention for staff to encourage her to use the call bell for assistance. On May 3, 2025, at 10:45 a.m., observation revealed that Resident 3 was in her room calling out for help. At that time, she stated, I need to go to the bathroom. When asked where her call bell was located, she was unable to locate it. Observation revealed that the call bell was draped over the night stand, hanging inside the open drawer of the night stand, and was out of her reach. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs identified in the comprehensive assessment for one of 30 sampled residents. (Resident 194) Clinical record review revealed that Resident 194 was admitted to the facility on [DATE], and had diagnoses that included retention of urine, Parkinson's disease, and dementia. The Minimum Data Set Care Area Assessment summary dated September 3, 2024, noted that the resident's urinary incontinence and cognitive decline/dementia were to be addressed in the care plan. There was no evidence that interventions to address Resident 194's urinary incontinence and cognitive decline/dementia were addressed in the current care plan. In an interview on October 9, 2024, at 2:40 p.m., the Director of Nursing confirmed there was no documented evidence that the identified care areas were addressed in Resident 194's current care plan and they should have been. 28 Pa. Code 211.12(d)(1)(5)Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for two of 30 sampled residents. (Residents 30, 202) Findings include: Clinical record review revealed that Resident 30 was admitted [DATE], with diagnoses that included diabetes (insufficient production of insulin, causing high blood sugar). A physician's order, dated, May 3, 2023, directed staff to take a finger stick measurement of the resident's blood sugar before each meal at 6:30 a.m., 11:30 a.m., and 4:30 p.m. Review of Resident 30's Medication Administration Record (MAR) revealed that on August 27, 2023, at 6:30 a.m., October 19, 2023, at 6:30 a.m., and October 25, 2023, at 11:30 a.m., there was a lack of documentation to support that staff took a measurement of the resident's blood sugar. A physician's order, dated July 13, 2023, directed staff to take Resident 30's weight every week on Thursday. Review of the record and the MAR for August, September, and October, 2023, revealed that there was a lack of documentation to support that staff weighed the resident weekly as ordered on eight of 13 occasions. Clinical record review revealed that Resident 202 was admitted [DATE], with diagnoses that included diabetes. A physician's order, dated October 2, 2023, directed staff to take a finger stick measurement of the resident's blood sugar twice a day at 6:00 a.m. and 4:30 p.m. Review of the MAR revealed that on October 3, 19, 20, and 22, 2023, at 6:00 a.m., there was a lack of documentation to support that staff took a measurement of the resident's blood sugar. In an interview on November 8, 2023, at 11:30 a.m., the Director of Nursing stated that there was no documented evidence to support that staff followed physicians' orders as identified above. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide treatment and services to prevent further decline in range of motion and contracture for one of 25 sampled residents. (Resident 45) Findings include: Clinical record review revealed that Resident 45 had diagnoses that included anoxic brain injury and contractures of the left and right hands. Review of the Minimum Data Set assessment dated [DATE], revealed Resident 45 was totally dependent on staff for activities of daily living and had limitations in range of motion on both sides of her upper extremities. Review of Resident 45's occupational therapy discharge recommendations on March 12, 2021, revealed that the resident was to continue a restorative splint and brace program for both hands. Review of the current care plan indicated that staff was to apply splints to the resident's left and right hands daily. On November 22, 2022, from 11:15 a.m. through 12:50 pm, and on November 23, 2022, at 11:30 a.m., Resident 45 was observed without splints to her left and right hands. In an interview on November 23, 2022, at 10:04 a.m. the Nursing Home Administrator stated that Resident 45 was on a restorative splinting program for her hands. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on clinical record review, review of the facility's incident investigation, and staff interview, it was determined that the facility failed to provide adequate supervision related to an elopement (unauthorized departure from the facility) for one of 25 sampled residents. (Resident 81) Findings include: Clinical record review revealed that Resident 81 was admitted to the facility on [DATE], with diagnoses including congestive heart failure and hypertension. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment and needed supervision from staff when off of the nursing unit. Review of the nurses notes revealed that on October 3, 2022, Resident 81 walked on the elevator and attempted to go downstairs. The nurse noted that a Wanderguard (a security apparatus worn by an at risk resident that prevents doors from opening to prevent elopement when the resident is nearby) was applied and the supervisor was made aware. Further review of the nurses notes revealed that on October 24, 2022, Resident 81 was found outside the facility in the parking lot by staff leaving the facility. Review of the facility's incident investigation revealed that Resident 81 did not have a Wanderguard on when he was found. There was no evidence to support that a Wanderguard was applied or monitored by staff as indicated by the nurse's note on October 3, 2022. In a interview on November 23, 2022, at 10:49 a.m. the Director of Nursing stated that there was no evidence that Resident 81's Wanderguard was monitored by facility staff and that in an interview, Resident 81 stated to her that he had cut off the Wanderguard applied on October 3, 2022, on an unknown date prior to the resident's elopement on October 24, 2022. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation and interview, it was determined that the facility failed to ensure that a resident's preference at meal times had been accommodated for one of 25 sampled residents. (Resident 54) Findings include: Clinical record review revealed that Resident 54 was admitted to the facility with diagnoses including diabetes mellitus and malnutrition. A Minimum Data Set assessment dated [DATE], indicated that the resident was alert and able to make his needs known. Resident 54's ongoing care plan revealed he had an altered nutrition status and an intervention was to honor his food preferences. During an interview on November 21, 2022, at 12:15 p.m. Resident 54 stated that he had told the dietary department that he disliked carrots and still received them often. Observation on November 21, 2022, at 12:40 p.m. revealed that the resident received diced carrots as a side with his meal. The resident's tray card indicated that the resident disliked carrots.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 30 sampled residents. (Resident 66) Findings include: Clinical record review revealed that Resident 66 was admitted to the facility on [DATE], and had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Care Area Assessment (CAA) dated November 5, 2021, the facility identified the resident's cognitive loss and antidepressant drug use was a problem and an individualized care plan with interventions was to be developed to address that need. There was no care plan developed or interventions to address the cognitive loss and the need for antidepressant medication administration for Resident 66. In an interview on December 16, 2021, at 11:25 a.m., the Director of Nursing confirmed that there was no care plan developed with interventions to address the cognitive loss and the need for antidepressant medication administration for Resident 66 28 Pa. Code 211.11(d) Resident care plan.

Based on observation, it was determined that the facility failed to store food under sanitary conditions in the kitchen and on one of three healthcare units. (The third floor) Findings include: During a tour of the kitchen on January 4, 2021, at 9:48 a.m., observation in the walk-in refrigerator revealed one metal pan of ham with a prepared date of December 26, and a use by date of December 29, one container of Sysco Classic California Pasta Salad labeled with a date of December 21, which was not indicated as date opened or use by date, and one container of Ricotta cheese with a manufacturer best by date of January 1, 2021. During the same kitchen tour, observation of the coffee station revealed a plastic container of thickening powder that was not labeled or dated and an uncovered metal dish of plastic spoons used for tasting, with small particles of unidentified debris on the spoons and in the pan. Observation of the refrigerator on the third floor healthcare unit revealed one plastic bag that contained a smaller bag of an unidentified food item that was not dated, and one insulated lunch bag storing a container of unidentified food items that was not dated. 28 Pa. Code 201.18 (b)(3) Management

Based on observation, clinical record review and interview, it was determined that the facility failed to provide adequate supervision to prevent accidents for one of 24 sampled residents. (Resident 35) Findings include: Clinical record review revealed that Resident 35 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was not alert and required extensive assistance for activities of daily living (ADLs). Clinical record review revealed, that Resident 35 fell from his Geri chair (large, padded chair) in the dining room on December 26, 2020. A review of the care plan dated December 28, 2020, revealed, the resident was at risk for falls due to impaired mobility, and staff was instructed not to leave the resident unattended in the dining after he has completed his meals. On January 6, 2021, the resident was observed unsupervised in his Geri chair in the dining room at 9:16 a.m., 12:40 p.m., and 1:05 p.m. Meals were not being served at these times. In an interview on January 6, 2021, at 1:24 p.m., the Director of Nursing (DON) confirmed Resident 35 should not be left in the dining room after meal times. 28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that behavioral health services was provided for one of 29 sampled residents. (Resident 13) Findings include: Clinical record review revealed that Resident 13 was admitted to the facility on (MONTH) 4, 2014, with [DIAGNOSES REDACTED]. According to the resident's care plan, the resident was at risk for behavior symptoms that included changes in mood due to depression and anxiety. A behavioral health specialist consultation, dated (MONTH) 12, 2019, revealed that the resident continued to have periods of agitation and anxiety that included refusal of medications and treatments. Consultant recommendations was to increase the dose of a previously prescribed mood-stabilizing medication and to continue to monitor the resident's behavior. On (MONTH) 21, 2019, the physician approved the recommendations to increase the mood stabilizing medication and continue behavior monitoring. The was no evidence in the clinical record to indicate that the behavioral health specialists' recommendation was implemented. A behavioral health specialist consultation, dated (MONTH) 23, 2019, confirmed that the resident was not receiving the increased dose of medication as recommended and continued to exhibit behaviors. In an interview on (MONTH) 8, 2019, at 10:30 a.m., the Director of Nursing confirmed that a medication dose change was not implemented. 28. Pa Code 211.12(d)(1) Nursing Services.

Based on clinical record review, review of select facility policies, review of facility documentation, and staff interview, it was determined that the facility failed to prevent resident neglect that resulted in a fall and serious injury for one of seven residents who sustained a fall resulting in a fractured left femur. This deficiency is cited as past non-compliance. (Resident CR1). Findings include: Review of the facility policy entitled, Bed Positioning dated October 2011, submitted by the facility to the Department on July 7, 2017, reflected that when turning a resident from back to side, staff was to, gently roll the patient toward you. Clinical record review revealed that Resident CR1 had been admitted to the facility on [DATE]. Documentation submitted by the facility to the Department on June 12, 2017, indicated that the resident had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment (MDS-a periodic assessment of resident care needs) dated May 13, 2017, reflected that the resident did not walk, and that she needed the extensive assistance of two staff for bed mobility. Review of the resident's Task List Report (a document used by the facility to communicate resident care needs to the nurse aides) reflected that since May 2, 2016, the resident required two staff for care. The care plan (a document that listed the resident's care needs and the measures that the staff were to implement to meet those needs) dated May 2, 2016, reflected that two staff members were needed for care delivery. Review of the information dated June 12, 2017, submitted by the facility reflected that on June 11, 2017, at 5 a.m. the resident was in bed and Employee 1, a Nurse Aide, had been providing incontinence care. The information reflected that Employee 1 had rolled the resident away from herself (away from Employee 1). The information indicated that the resident had fallen from bed to the floor. The resident was transferred to the hospital where she was found to have a fractured left femur (thigh bone). Facility documentation reflected that the resident underwent [REDACTED]. Facility documentation reflected that in an interview on June 13, 2017, Employee 1 admitted that the resident fell off the bed when she (Employee 1) had rolled the resident away from herself. In this interview, Employee 1 also admitted that she had been providing care alone when the resident fell off the bed. In a report initially submitted to the Department on June 15, 2017, the facility alleged that Resident CR1' s fall was the result of neglect by Employee 1. The facility documented that Employee 1 did not follow, proper protocol for bed positioning and did not ask for help with the resident. The facility documented that the allegation of neglect, was substantiated and (Employee 1) was at fault. In an interview on August 16, 2017, at 2:25 p.m. the Director of Nursing stated that Employee 1 failed to roll the resident towards her while providing incontinence care and bed linen change, that resulted in a fall with injury on June 11, 2017. This deficiency is cited as past non-compliance. On June 12, 2017 and continued to August 3, 2017, (inclusive) the facility provided all staff with educational inservicing, updated the staff assessment tool (Kardex) to reflect the resident's care needs, and required signed staff acknowledgement confirming their understanding of care expectations. The facility's corrective action plan was an audit of all the resident's safety, skin care, bowel/ bladder, skin care, activities of daily living/ restorative care, food/ fluids, and notification to the responsible party of changes in condition. The Director of Nursing/designee will re-educate licensed personnel on resident care needs and monitoring will be conducted to assess resident change in condition. All resident care needs will be reflected on the resident's individualized care plan. Findings will be summarized and reported at the Quality Assurance Performance Improvement (QAPI) meeting. QAPI Committee will determine the need for further audits and/or recommendations for systematic modification. All of this information was verified during the onsite survey and a hard copy of all the documentation was provided to the survey team. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies Previously cited 7/1/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 7/1/16, 8/14/15