Every finding on record at Chapel Pointe at Carlisle

Based on clinical record review, staff interview, and Centers for Medicare and Medicaid Services publication, it was determined that the facility failed to complete a Significant Change Minimum Data Set after a significant change was identified for one of two residents reviewed for hospice services (Resident 45). Findings include: Review of Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.19.1 (instructions on when and how to complete the Minimum Data Set), revealed it stated, An [Significant Change in Status Assessment; a.k.a. Significant Change Minimum Data Set] is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The [Assessment Reference Date] must be within 14 days from the effective date of the hospice election . Review of Resident 45's clinical record revealed diagnoses that included Alzheimer's disease (progressive, irreversible degenerative disease of the brain that results in decreased contact with reality and decreased ability to perform activities of daily living) and hypertension (elevated/high blood pressure). Review of Resident 45's clinical record revealed that on July 22, 2024, Resident 45 entered into hospice services. Review of the Minimum Data Set (MDS) assessment history for Resident 45 revealed that a Significant Change MDS was not completed until September 13, 2024; 53 days after Resident 45 had entered into hospice services. During a staff interview on March 13, 2025, at approximately 11:10 AM, Nursing Home Administrator (NHA) confirmed that the Registered Nurse Assessment Coordinator identified that Resident 45 did not have a Significant Change MDS completed within 14 days, and subsequently completed the Significant Change MDS with an assessment reference date of September 13, 2024. During the interview, the NHA confirmed that it was the facility's expectation that Significant Change MDS assessment are completed within 14 days after the facility identifies significant change in resident condition. 28 Pa code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 17 residents reviewed (Residents 7 and 20). Findings Include: Review of Resident 7's clinical record revealed diagnoses that included congestive heart failure (CHF- a chronic condition in which the heart doesn't pump blood as well as it should) and Type 2 Diabetes Mellitus (when the body cannot use insulin correctly and sugar builds up in the blood). Review of Resident 7's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) dated November 1, 2024, revealed that in Section N, opioid medication (a class of drug used to reduce moderate to severe pain) was not checked as being received by the resident during the last seven days. Review of Resident 7's medication administration record (MAR), dated October 2024 and November 2024, revealed that Resident 7 received Tramadol (an opioid medication) every day. On March 13, 2025, at 11:47 AM, the Nursing Home Administrator (NHA) confirmed that Resident 7 received the Tramadol and that the opioid medication should have been coded on the MDS. Review of Resident 20's clinical record revealed diagnoses that included Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors) and Type 2 Diabetes Mellitus. Further review of Resident 20's clinical record revealed that he was admitted to the hospital on January 1, 2025, and readmitted to the facility on [DATE]. Review of Resident 20's hospital discharge summary, dated January 3, 2025, revealed that he was diagnosed with a UTI (urinary tract infection) during his hospital admission. Review of Resident 20's physician note, dated January 3, 2025, revealed that Resident 20 was diagnosed with a UTI during his hospitalization . Review of Resident 20's MAR, dated January 2025, revealed that Resident 20 received Levaquin (antibiotic) on January 4-7, for treatment of his UTI. Review of Resident 20's significant change MDS, dated [DATE], revealed in section I, it was not coded that Resident 20 had a UTI in the past 30 days. Further review of the MDS revealed in Section N, it was not coded that Resident 20 received an antibiotic in the past seven days. On March 13, 2025, at 10:32 AM, the NHA stated that the UTI was missed being coded on the MDS and one day of antibiotic should have been coded during the seven day lookback period. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for three of 18 residents reviewed (Residents 24, 46, and 55). Findings include: Review of Resident 24's clinical record revealed diagnoses that included major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in daily activities), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and Stage 3 Pressure Ulcer (a full thickness tissue loss wound where the tissue just under the skin may be visible, but no bone, tendon, or muscle is exposed) of the sacral region (the portion of the spine between the lower back and tailbone). Review of Resident 24's care plan revealed problems for Impaired skin integrity which indicated a goal of: Resident's current stage 3 coccyx pressure ulcer will resolve without complications or infection and Resident will develop no further skin breakdown, with a goal date of November 24, 2022. Further review revealed a care plan for Risk for skin integrity impairment related to Braden Assessment (an assessment tool used to identify a person's risk level for skin breakdown) and risk factors of diabetes, limited mobility, incontinence, poor appetite with weight loss, declining health, and need for increased assistance with activities of daily livings, which indicated a goal of: Resident will be free of skin breakdown, with a goal date of November 24, 2022. Resident 24 also had a care plan for Psychotropic (medications that affect a person's mental state) drug use with potential drug related complications related to antidepressant and antianxiety medication use with diagnoses of major depressive disorder and anxiety disorder; recent weight loss; and reports feeling depressed and tired, which indicated a goal of: will remain free of drug related cognitive/behavioral impairment; gait disturbance; hypotension; movement disorder, with a goal date of December 7, 2022. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on May 10, 2023, at 2:40 PM, the concern of Resident 24's care plan goal dates was shared for further follow-up. Email communication received from NHA on May 10, 2023, at 6:18 PM, indicated that Resident 24's care plan goal dates were revised. During an interview with the NHA on May 11, 2023, at 9:45 AM, she confirmed that she would have been expected the care plan to be updated accordingly. Review of Resident 46's clinical record revealed diagnoses that included dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and gastro esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining). Review of Resident 46's current physician's orders on May 8, 2023, revealed a physician's order for a regular diet, soft to chew texture, regular/thin consistency, no straws, and food cut into small bite sized pieces, with a start date of March 31, 2023. Review of Resident 46's care plan revealed a care plan for: Potential risk for altered nutritional status related to end stage dementia. This care plan had an intervention of: use a lid and straw when drinking liquids, with a start date of March 31, 2023. Interview with the NHA on May 10, 2023, at 6:14 PM, revealed that the physician's order was correct, and that Resident 46 was not supposed to be using straws and the care plan should have been changed to reflect that. Review of Resident 55's clinical record revealed diagnoses that included chronic kidney disease (long-standing disease of the kidneys leading to renal failure-a condition in which the kidneys lose the ability to remove waste and balance fluids). Review of Resident 55's physician orders revealed the following order: Dialysis treatment per schedule, with a discontinued date of March 6, 2023. Review of Resident 55's care plan revealed a care plan problem for potential for dehydration (dangerous loss of body fluid caused by illness, sweating, or inadequate intake) related to renal failure (condition in which the kidneys lose the ability to remove waste and balance fluids) with hemodialysis (a treatment to filter wastes and water from one's blood as the kidneys would do when they were healthy); history of urinary tract infections and septicemia (a life-threatening complication of an infection that occurs when the chemicals released by the body into the blood stream to fight an infection trigger inflammation throughout the body); needs encouraged to hydrate, with a goal date of May 1, 2023. During an interview with the NHA and DON on May 10, 2023, at 2:40 PM, the concern of Resident 55's potential for dehydration care plan problem not being revised to indicate a history of hemodialysis under for further review and follow-up. Email communication received from NHA on May 10, 2023, at 6:18 PM, indicated that Resident 55's care plan was changed to say renal failure with history of dialysis. During an interview with the NHA on May 11, 2023, at 9:45 AM, she confirmed that she would have been expected the care plan to be updated accordingly. 42 CFR 483.21(b) Comprehensive Care Plans 28 Pa. Code 211.11(d)(e) Resident care plan 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food in a safe and sanitary manner in the main dietary kitchen and in two of three nourishment pantries (Main dietary kitchen, fell owship Place Pantry, and Family Place Pantry). Findings include: Review of facility policy, titled Food Storage, last reviewed July 13, 2022, revealed the policy stated At times food may be opened from its original storage container but not used - these unused food items may be returned to storage if completely wrapped or placed in appropriate storage container with lid to prevent infestation. These products must be labeled with the date opened and what the item is if not readily apparent .Any food items with a manufacturers expiration date must be used prior to expiration date or discarded on expiration date .Prepared foods that have not been used must be discarded if not used within 72 hours. Observation in the Main dietary kitchen on May 8, 2023, at approximately 6:45 PM, revealed multiple potatoes on a baking pan located on the lower shelf of a preparation table. The preparation table was located between the Main dietary kitchen's walk-in freezer and walk-in refrigerator. Observations of the potatoes revealed that they were not labeled or dated. Observations in the Main dietary kitchen on May 9th, 2023, at approximately 11:10 AM, revealed the potatoes were still stored in the same location. Observations of the Family Place Pantry area on May 8, 2023, at approximately 7:00 PM, revealed the following: one container of mandarin oranges, one container of fruit mix, and one container of cocktail sauce that were beyond the identified expiration date; one container of pears, one pan of cake, one bag of apples, and one bag of bagels that did not have an opened date; multi-colored cereal stored in a plastic, zip-closure bag with no label or date written on the bag; and one container of a brown powdered substance, with a smell consistent with cinnamon, that had no label or date. It was also observed that oranges were stored in a bag labeled chicken, which had an expiration date of June 25, 2022, written on the bag. Further observations of the Family Place Pantry area revealed multiple staff personal items were stored in a drawer in the pantry area. Items observed included a staff water bottle, sweatshirt, hair brush, and fragrance spray. Observation of the refrigerator in the fell owship Pantry area on May 8th, 2023, at approximately 7:15 PM, revealed one container of butter and one container of creamer that were open but not dated. Observations of a freezer unit revealed two zip-close bags of what appeared to be chicken, that was not labeled or dated. During a staff interview on May 11, 2023, at approximately 11:00 AM, Nursing Home Administrator (NHA) revealed it was the facility's expectation that food items are labeled and dated. During the staff interview, NHA revealed that staff personal items are not to be stored in the pantry area, and that the facility has designated areas for staff to store their personal items. 28 Pa code 211.6(f) Dietary services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 18 residents reviewed (Residents 29 and 46). Findings Include: Review of Resident 29's clinical record revealed diagnoses that included congestive heart failure (CHF- a chronic condition in which the heart doesn't pump blood as well as it should), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety. Further review of Resident 29's clinical record revealed that Resident 29 was transferred and admitted to the hospital on March 18, 2023, after a fall, resulting in a left femur fracture and right calcaneus (heel bone) fracture. Resident 29 was readmitted to the facility on [DATE]. Review of Resident 29's MDS assessments (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs), revealed Resident 29 had a significant change MDS assessment completed on March 29, 2023, which was the first assessment completed after Resident 29's re-entry to the facility. Review of Resident 29's significant change MDS dated [DATE], revealed that in Section A0310E, which asks Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry? was coded as 0/No. Review of section J1700, Fall History on Admission/Entry or Reentry, revealed Complete only if A0310A = 01 or A0310E = 1. Since section A0310E was coded as a 0, Section J1700 was not coded and Resident 29's fall with fracture was not captured on the MDS. In an email correspondence from the Nursing Home Administrator (NHA) on May 10, 2023, at 6:00 PM, she stated that Section A was miscoded and, therefore, did not populate for J1700. She stated that a modification MDS has been completed. In a follow up interview with the NHA on May 11, 2023, at 11:11 AM, she confirmed that Resident 29's MDS was coded incorrectly in Section A, which caused Section J to not capture Resident 29's fall with fracture. Review of Resident 46's clinical record revealed diagnoses that included dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and gastro esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining). Review of Resident 46's physician's orders revealed an order dated November 11, 2022, to discharge Resident 46 from hospice services on November 16, 2022. Review of Resident 46's MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated November 25, 2022, revealed that Section O0100k. Hospice Care was not checked, indicating that Resident 46 had not received hospice care in the previous 14 days while a Resident or while not a Resident. Also, O0100z. None of the above, was checked indicating that Resident 46 did not receive any of the above treatments (including hospice care) in the previous 14 days Interview with the NHA on May 10, 2023, at 6:14 PM, revealed that Resident 46 had received hospice services during the 14-day look-back prior to the November 25, 2022, MDS and should have been marked accordingly. 28 Pa. Code 211.5(f) Clinical records 28 Pa Code 211.12 (d)(3)(5) Nursing Services

Based on observation, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of five residents reviewed for pressure ulcers (Resident 4). Findings Include: Review of facility policy, titled Dressings: Clean, with a review/revision date of November 2021, revealed Remove soiled dressings and discard in bag. Remove gloves. Wash hands. Put on clean gloves. Use either swabs or gauze pads to clean area. Review of Resident 4's clinical record revealed diagnoses that included heart failure, atrial fibrillation (A-fib - an irregular, often rapid heart rate that commonly causes poor blood flow), and left hip pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin). Review of Resident 4's current physician orders revealed an order dated April 28, 2023, to cleanse left hip pressure ulcer with normal saline solution (NSS), apply skin prep to around wound, apply calcium alginate with silver to wound bed, and cover with foam dressing. Observation of Resident 4's dressing change to the left hip pressure ulcer on May 10, 2023, at 10:45 AM, revealed Employee 1 performing hand hygiene and applying gloves. Employee 1 then removed Resident 4's old dressing and discarded it into the trash. Employee 1 then cleansed Resident 4's pressure ulcer with NSS. Employee 1 did not remove her gloves, perform hand hygiene, and apply a new pair of gloves after removing the old dressing and before cleansing the pressure ulcer with NSS. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing on May 11, 2023, at 11:09 AM, the NHA stated that the facility policy should have been followed; and Employee 1 should have changed her gloves and performed hand hygiene after removing the old dressing and prior to cleansing the wound. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that the pharmacy regimen review was completed for one of five residents reviewed for unnecessary medications (Resident 4). Findings include: Review of the facility policy titled Consultant Pharmacist Reports IIIA1. Medication Regimen Review dated February 5, 2018, revealed that the consultant pharmacist reviews the medication regimen of each resident at least monthly and that at least monthly the consultant pharmacist reports any irregularities to the attending physician, Medical Director, and Director of Nursing, at a minimum. The review includes a review of pharmacy and clinical records, prescriber's orders, progress notes of prescribers, nurses, and/or consultants to identify irregularities. The policy also indicated the following: resident specific irregularities and/or clinically significant risks resulting from associated medications are documented in the resident's active record and reported to the Director of Nursing, Medical Director, and/or prescriber; if a continuing irregularity is deemed to be clinically insignificant, or evidence of a valid clinical reason for rejecting the recommendation is provided, the consultant pharmacist will reconsider whether to report the irregularity again or make a new recommendation on an annual basis; and the prescriber accepts and acts upon suggestion or provides an explanation for disagreeing. Review of Resident 4's clinical record revealed diagnoses that included major depressive disorder (mental disorder characterized by at least two weeks of low mood that is present across most situations). Review of monthly pharmacy medication regimen review documentation revealed that the pharmacist had conducted all monthly reviews. On November 15, 2021, the Pharmacist Note to Attending Physician/ Prescriber indicated that Resident 4 had been taking [MEDICATION(S)] 40 mg once daily (a medication used to treat depression) since June 2021, and that the pharmacist recommended that it be reviewed for a gradual dose reduction. The physician marked disagree on the recommendation form and signed and dated the recommendation on November 24, 2021, with no rationale for the disagreement provided. Interview with Nursing Home Administrator (NHA) on June 2, 2022, at 11:05 AM, indicated that she would have expected the physician to document a rationale for disagreeing with the pharmacist recommendation. On February 22, 2022, the pharmacist log of visits indicated that the monthly review was completed and that the pharmacist recommended a Complete Blood Count (a laboratory test that provides information about the cells in a person's blood) and a Basic Metabolic Profile (a laboratory test used to check the health of the kidney's, electrolytes, and blood glucose levels, all which are related to the body's metabolism) be obtained. There was no Pharmacist Note to Attending Physician/ Prescriber located in the chart. On March 9, 2022, the pharmacist log of visits indicated that the monthly review was completed and that the pharmacist made no recommendations. There was no documented follow-up on the unaddressed recommendation from the February. On April 18, 2022, the pharmacist log of visits indicated that the monthly review was completed and that the pharmacist, again, recommended a Complete Blood Count (a laboratory test that provides information about the cells in a person's blood) and a Basic Metabolic Profile (a laboratory test used to check the health of the kidney's, electrolytes, and blood glucose levels, all which are related to the body's metabolism) be obtained. There was no Pharmacist Note to Attending Physician/ Prescriber located in the chart. On May 17, 2022, the pharmacist log of visits indicated that the monthly review was completed and, although the pharmacist made recommendations, the unaddressed recommendation from April 18, 2022, was not mentioned. Interview with NHA on June 1, 2022, at approximately 01:50 PM, revealed that she had contacted the pharmacist regarding the missing recommendations. She indicated that, according to the Pharmacist, they were showing on his side of the system, but not on the side of the facility. The pharmacist provided a copy of the recommendation to the NHA at that time. She also indicated that the pharmacist was contacting software company, but that, in the meantime, the facility followed-up with Resident 4's primary care physician and obtained orders for the labs to be obtained every six months starting in July. The Note to Attending Physician/ Prescriber provided by NHA on June 1, 2022, at approximately 01:50 PM, indicated that Resident 4 was due for a Complete Blood Count (a laboratory test that provides information about the cells in a person's blood) and a Basic Metabolic Profile (a laboratory test used to check the health of the kidney's, electrolytes, and blood glucose levels, all which are related to the body's metabolism), because those taking a Selective Serotonin Reuptake Inhibitor (a class of drugs used as antidepressants in the treatment of major depressive disorder) should be evaluated every six months to verify the safety of their therapy. Email correspondence from the NHA on June 2, 2022, at 9:31 AM, indicated that the pharmacist would inspect this Resident's files since this seems to be an isolated case as the facility received the other recommendations for that date. She also indicated that the pharmacist spoke with RxPertise and they could not pinpoint the problem since it seems to be working now, they said it could have been a Windows issue. They went over a few things they know that can cause this, but it didn't seem to be causing it this time. Interview with NHA on June 2, 2022, at 11:05 AM, indicated that she would have expected the pharmacist to re-address unanswered recommendations as identified in the policy, but he could have been waiting for her routine physician visits. 28 Pa. Code 211.2(a) Physician services. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to maintain an effective infection control program related to the use and cleaning/sanitizing of resident care equipment for three of six residents observed (Residents 36, 47, and 51). Findings include: Review of the facility policy titled Pulse Oximeter (small finger unit) revealed the pulse oximeter is a portable device used to measure and display functional oxygen saturation of arterial hemoglobin (%SpO2) and pulse rate of residents who are well or have poor profusion. The policy further revealed staff are to wipe the surfaces of the pulse oximeter with an alcohol sponge/disinfectant wipe and allow to dry after each use. An observation on June 1, 2022, at approximately 8:33 AM, revealed Employee 1 placing the pulse oximeter on Resident 36's finger and obtaining a reading; the Employee did not clean the meter after use. An observation on June 1, 2022, at approximately 8:46 AM, revealed Employee 1 placing the pulse oximeter on Resident 47's finger and obtained a reading; the Employee did not clean the meter after use. An observation on June 1, 2022, at approximately 8:54 AM, revealed Employee 1 placing the pulse oximeter on Resident 51's finger and obtaining a reading ; the Employee did not clean the meter after use. Interview with Employee 1 on June 1, 2022, at 9:02 AM, revealed she cleans the meter at the beginning and at the end of her shift, and then will clean the meter if the Resident's fingers are visibly soiled or sticky. Interview with the Nursing Home Administrator on June 1, 2022, at 1:55 PM, revealed she would expect the employees to clean the pulse oximeter after use with each resident. 28. Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on observations, record review, and staff interviews, it was determined that the facility failed to maintain a safe, homelike environment for one resident reviewed (Resident 2). Findings include: Observation on April 21, 2022, at 10:00 AM, revealed Resident 1 and Resident 2's rooms are located next to each other. Inside both rooms is a door to enter a shared bathroom. Review of Resident 1's medical record revealed resident is care planned for behavioral issues including being physically combative towards staff, verbally threatening towards other residents and staff, having socially inappropriate behavior at times disturbing towards other residents, having sexually inappropriate behavior towards other residents and staff, and urinating on floors and walls. Review of Resident 2's medical record revealed resident is care planned for paranoia over her things in her room and concern noted with bathroom mate entering her room when she is in bed due to her history of paranoia and misreading other's intent. Review of Resident 1's progress note dated March 26, 2022, at 4:36 AM, revealed Resident 1 was observed in Resident 2's room going through the dresser drawers and pressing a pair of underpants against Resident 1's face. The note further revealed Resident 1 began yelling saying he was allowed in that room. Review of Resident 1's progress note dated April 17, 2022, at 5:48 AM, revealed Resident was angry and striking out at staff, then ambulated to Resident 1's room. At 7:21 PM, Resident 1 was attempting to go into other resident's rooms. Review of Resident 2's progress note dated April 15, 2022, at 5:32 AM, revealed Resident 1 had entered Resident 2's room at 4:45 AM. Resident 1 was not wearing any clothing and had pulled Resident 2's covers down and was peeing at the foot of Resident 2's bed. Review of Resident 1's progress note dated April 20, 2022, at 4:36 AM, revealed resident went through shared bathroom door and attempted to enter Resident 2's door. Review of Resident 1's progress note dated April 21, 2022, at 4:15 AM, revealed Resident 1 was found attempting to enter Resident 2's room stating, I have to pee. Interview with the Director of Nursing on April 21, 2022, at approximately 11:00 AM, revealed they had discussed installing a lock to the bathroom door into Resident 2's room so Resident 1 could not enter through the shared bathroom. Interview with the Nursing Home Administrator (NHA) on April 21, 2022, at approximately 1:15 PM, revealed Resident 1's behaviors have started again in February. The Resident is ordered to be checked every 15-minutes by staff, and there is an extra staff member coming in at 4:00 AM to assist with monitoring. Further correspondence with the NHA on April 22, 2022, revealed the Care Plan for Resident 2 has been updated to include placing Resident 2's chair in front of the shared bathroom door to prevent Resident 1 from entering the room. Education of staff and care plan finalization was completed April 21, 2022. 28 Pa. Code 207.2(a) Administrator's responsibility. 28 Pa. Code 201.18(b)(1) Management.

Based on observation, interview, and resident handbook review, it was determined that the facility failed to provide resident's access to file an anonymous grievance in 2 of 3 households reviewed (Household 1 FEP and Household 2 FAP). Findings include: General observations on June 14, 2021, at approximately 10:00 AM, revealed signage posted in the households (also known as FEP and FAP) that stated, Please refer to the Resident & Visitor Information Book located in the bookcase by the fireplace. Please note Department of Health contact information and the Ombudsman State Advocacy Poster is posted in the Main Household Reception area. Further review of the signage revealed the Resident and Visitor Information Book, contained the following information, Meal Services, State and Federal and Building Survey Results, Resident Rights and Abuse, Miscellaneous Notices, Licenses, Government Agency Contact, Privacy Policy. Observation of the Resident & Visitor Information Book on Household 1 revealed that it was located on the bookcase, and the bottom of the notebook was approximately 5 feet from the floor, and not within reach of a person sitting in a wheelchair. Observation of the Resident & Visitor Information Book on Household 2 revealed it was located on the bookcase approximately 3 feet from the floor and located behind a decorative flag, not easily visible to residents or visitors. Observation of Household 1 (also known as FEP) revealed no grievance forms were accessible to residents residing in Household 1. During a staff interview on June 16, 2021, at approximately 11:20 AM, Licensed Practical Nurse (LPN) 1, on Household 1, was asked, .if a resident wanted to file a grievance how would they do that? LPN 1 stated residents would have to request a form,from a staff member. LPN 1 then showed a drawer within the nurse's station where she stated the grievance forms are filed. Observation of Household 2 (also known as FAP) revealed no grievance forms were accessible to residents residing in Household 2. During a staff interview on June 16, 2021, at approximately 11:37 AM, Registered Nurse (RN) 2 was asked, .if a resident wanted to file a grievance how would they do that? RN 2 stated that she would have to ask someone, then RN 1 picked up the phone and called the Social Worker. RN 2 was unable to talk with social services but another staff person, LPN 1, returned the call, and informed RN 2 there is no form to file a grievance, and that residents are to discuss their issues with staff who must report the issue to the social worker, or the Director of Nursing. A review of the resident council minutes on June 16, 2021 at approximately 11:45 AM, revealed no documented discussion on how to file an anonymous grievance. Review of the facility's resident handbook revealed it did not include how to submit a grievance, nor how to submit a grievance anonymously. The facility was unable to provide any grievances that were lodged over the past year. Further review of the facilities grievance process revealed that only written grievances will be responded to in writing. During an interview with the Nursing Home Administrator (NHA) on June 16, 2021, at approximately 1:45 PM, she stated that there is no grievance form, and that residents are expected to discuss their concerns with staff. The NHA then stated there is a box outside the households near the reception area that notes may be placed if the complainant wants to remain anonymous. Review of the resident handbook an Resident & Visitor information book fail to state anything about the box located outside of the households. 28 Pa. Code 201.29(i)Resident rights.

Based on clinical record review, observation and staff interviews it was determined that the facility failed to follow the care plan to meet the needs of one out of 18 residents reviewed (Resident 38). Findings include: Review of Resident 38's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Registered Nurse (RN) 1 on June 15, 2021, at approximately 10:00 AM, RN 1 revealed that Resident 38's medical concerns also included that due to his hallucinations and double vision, they had started the use of a solid color placemat under his plate. RN 1 then further explained that because of the hallucinations, when he saw a pattern on a place mat (used during meals) he thought it was bugs and he would keep trying to remove them. She revealed that if the back of a mat is white, that that works as a solid color for him as staff would just turn it over. Observation was made on June 15, 2021, at 12:20 PM, in Resident 38's dining room during lunch meal that Resident 38 was finishing with main part of his meal and that there was a white placemat with a wide colored floral design around the whole perimeter of it. Interview was completed with Homemaker (HM) 1 at this time. When asked if they have solid color placemats on hand, HM 1 stated not often and also volunteered that she usually just flips it over. During an interview with RN 1 on June 15, 2021, at approximately 12: 47 PM , RN 1 revealed that the placemat should have been turned over. Review of Resident 38's current active Comprehensive Care Plan on June 15, 2021, at 1:20 PM revealed the Care Focus Area of Potential Risk for Altered Nutrition Status R/T (due to) Parkinsons's Disease. Dysphagia with a noted start date of November 12, 2020. Review of associated interventions included Lipped plate, scooped bowl, and a solid color placemat at meals with an associated start date of November 12, 2020. During an interview with Nursing Home Administrator (NHA) on June 15, 2021, at 2:02 PM the NHA revealed the expectation that Resident 38's placemat should have been flipped over to be a solid color. During an interview with NHA on June 16, 2021, at approximately 12:50 PM, the NHA revealed the expectation that Resident 38's Care Plan would have been followed regarding the placemat not being flipped over to be a solid color. 28 Pa. Code 211.11(a) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation, review of facility policy, and staff interviews it was determined that the facility failed to serve food in accordance with professional standards for food service safety in one out of one nursing unit dining areas observed (FRC). Findings include: Lunch meal observation was conducted in FRC dining room on June 15, 2021. Observation was made at 12:31 PM that Household Coordinator (HC) 1 was observed to remove a consumed meal/dishware from a resident (with bare hands) and place in proper area for cleaning, she was then observed to enter the general food serving area, wash her hands, and proceeded to step over to the front counter area and without donning gloves used an ice cream scoop to dish up ice cream from a bulk (grocery store size ) container for a resident, requiring the other bare hand to hold the container steady. On June 16, 2021, at approximately 12:50 PM, the NHA was apprised that an additional observation made when HCA 1 was dishing up the resident's ice cream was that she was not wearing gloves. The NHA asked for clarification as to whether HC 1 had washed her hands and used an utensil to dish the ice cream. When this was confirmed by surveyor, the NHA revealed that the practice was OK. The NHA was asked if there was a reference source regarding the policy statement related to determination of minimal chance of contaminating food. The NHA revealed that this probably was determined when the renovations were done to make the facility more homelike. Review of facility document Versatile worker for meal service support/ When Household staff are covering the meal service section Gloves and handwashing revealed Disposable gloves should be worn when handling of ready to eat foods without utensils and handling any food that does not require further cooking or processing and Disposable gloves do not need to be worn when: handling raw foods that will be cooked, cleaning kitchen equipment, handling trash and Disposable gloves need to be changed or removed when: gloves become torn, dirty or contaminated, changing serving utensils, before starting another job, when leaving work area or going on break or to the restroom, when in doubt change your gloves. During interview with the NHA on June 16, 2021, at approximately 1:45 PM, the NHA revealed continued support of facility efforts to provide a more homelike environment as validation for the concerns presented above. 28 Pa Code 211.6(b)(d) Dietary Services

Based on observation, interview, record review, and policy review it was determined that the facility failed to post any signage to indicate a resident was on transmission based precautions (isolation to prevent the spread of bacteria) or to report to the nurse prior to entering the room for 1 of 1 residents reviewed on contact precautions, Resident 400. Findings include: A review of the clinical record for Resident 400 on June 14, 2021, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on June 16, 2021, at approximately 10:00 AM, revealed no signage indicating resident 400 was on contact precautions. The initial matrix provided by the facility failed to list Resident 400 on contact precautions. Resident 400 is in a locked household. When the surveyor entered the unit for the initial tour staff failed to inform surveyor that a resident was on contact precautions. The facility policies on C-diff and contact precautions were received and reviewed on June 16, 2021 at 8:33 AM. The policy, titled C-Diff Policy for Infected Residents, last revised May 23, 2019, states contact isolation will be instituted for the resident and staff will wash hands frequently. The policy titled, Contact Precautions last revised May 23, 2019, state The licensed nurse shall update family, visitors, and staff prior to entering the resident's room of resident's special care needs and protocol .Hands shall be washed upon entering the room and again before leaving the room with antimicrobial soap . Hand washing procedure shall be followed. During an interview on June 16, 2021, at approximately 9:21 AM, Nurse Aide (NA) 1 stated the facility doesn't use any signage at the resident's room entrance to indicate contact precautions. NA 1 was asked if items are stored in the resident's room such as personal protective equipment (gowns, gloves, masks), a container for soiled linen, gowns etc and she replied no and pointed to a stand approximately 6-7 feet from the entrance of the resident's room where there was a wooden cabinet placed that had gowns, gloves, and the hand sanitizer. The cabinet supplies were verified by NA 1 to be used for the care of Resident 400. NA 1 was asked how hands are cleaned prior to, and after caring for the resident and she pointed to hand sanitizer on the hall stand. NA was asked if she was aware of the resident's reason for contact precautions and she replied yes, c-diff. During an interview with the Nursing Home Administrator she stated that they prefer not to post signage about contact precautions or to see a nurse prior to entering the resident room to make the environment less institutionalized. There was signage indicating a green zone for COVID-19 status and the facility also places a flower on the resident's door to indicate a pending COVID-19 testing status. 28 Pa. Code 211.12(1)(2)(5)Nursing services. 28 Pa. Code §211.10(d) Resident care policies

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that care and services were provided to attain or maintain the resident's highest level of well-being for one of 20 residents reviewed (Resident 39). Findings include: Review of Resident 39's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 39's current active physician orders [REDACTED]. NO BM IN 3 DAYS and [MEDICATION NAME] Rectal Suppository 10 mg 1 Suppository PER RECTUM PRN 1 Time a Day-PRN for constipation: SPECIAL INSTRUCTIONS: IF NO BM IN 4 DAYS (ADMINISTER 11-7 shift) and Fleet Enema Rectal Enema 7-19 GM/118 ML 1 Applicator full PER RECTUM PRN 1 Time a Day-PRN for Constipation SPECIAL INSTRUCTIONS; IF NO BM IN 5 DAYS (ADMINISTER 7-3 SHIFT) IF NOT WARM WATER ENEMA, and also ENEMA WARM WATER 1 Application Instill to rectum PRN 1 Time a Day-PRN for Constipation SPECIAL INSTRUCTIONS; IF NO BM IN 5 DAYS (ADMINISTER 7-3 SHIFT) IF NOT FLEET ENEM[NAME] All five orders revealed to have initiation dates of (MONTH) 19, (YEAR), through (MONTH) 13, 2019. Review of facility form (Bowel Retraining 30 day review Resident Detail) used to document Resident 39's bowel function from (MONTH) 15 through (MONTH) 15, 2019, revealed that Resident 39 did not have bowel movements (BM) from (MONTH) 21 through 25, 2019, (5 days); from (MONTH) 27 through 29, 2019, (3 days); from (MONTH) 2 through 6, 2019, (5 days); from (MONTH) 8 through 11, 2019, (4 days); from (MONTH) 14 through 17, 2019 (4 days); from (MONTH) 19 through 22, 2019 (4 days); from (MONTH) 24 through (MONTH) 26, 2019, (3 days); from (MONTH) 1 through 3, 2019, (3 days) and from (MONTH) 8 through 11, 2019, (4 days). Review of Resident 39's August, September, and October, 2019, Medication Administration Record [REDACTED]. Fruit mix was revealed to be requiring administration as per orders nine times with one administration documented as given and no resident refusal documented. Milk of Magnesia was revealed to be requiring administration as per orders six times with one administration documented as given and no resident refusal documented. [MEDICATION NAME] Suppository was revealed to be requiring administration as per orders two times with no administrations documented as given and no resident refusal documented. During an interview with the Director of Nursing (DON) on (MONTH) 17, 2019, at 1:10 PM, the DON revealed that the bowel protocol should have been followed or the physician notified to reassess. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation, policy review and clinical record review, it was determined that the facility failed to ensure that respiratory equipment was changed for one of three residents reviewed with oxygen (Resident 16). Findings Include: Review of facility policy titled, Oxygen Administration, with a review date of (MONTH) 14, 2009, revealed that under Humidifier Use Guidelines- H20 (water) level to be checked nightly by the 10p to 6:30a shift. Further review of the policy revealed that 11-7 Licensed Nurse shall change resident's oxygen tubing, cannula, mask, or humidifier if used, every 7 days or as needed. Document on resident's monthly TAR (Treatment Administration Record). Review of Resident 16's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 16's current physician orders [REDACTED]. During an observation on (MONTH) 15, 2019, at 9:55 AM revealed that Resident 16's humidification bottle on her oxygen concentrator was dated (MONTH) 29, 2019. Resident 16 told the surveyor that she only wears the oxygen as she needs it but stated she has worn it the past three nights. At the time of the observation, Resident 16 was not wearing the oxygen. Observation on (MONTH) 16, 2019, at 9:55 AM revealed the same humidification bottle was on the oxygen concentrator, dated (MONTH) 29, 2019. Review of Resident 16's TAR dated (MONTH) 2019, revealed that oxygen was applied on (MONTH) 17. Review of Resident 16's TAR dated (MONTH) 2019, revealed that oxygen was applied on (MONTH) 13. During an interview with the Director of Nursing (DON) on (MONTH) 17, 2019, at 11:25 AM she stated that staff must have only changed the oxygen tubing and not the bottle, as the tubing is signed off on the TAR as being changed on (MONTH) 13, 2019. During an additional interview on (MONTH) 17, 2019, at 1:45 PM the DON stated that the humidification bottle gets changed every seven days from the day of use. It was used (MONTH) 17, changed (MONTH) 29, and not used again until (MONTH) 13, so it would be changed seven days after (MONTH) 13. 28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on record review and interview it was determined that the facility failed to follow the care plan to meet the needs of two of 24 residents reviewed, (Resident 11, and 28). Findings include: Review of Resident 11's clinical record revealed [DIAGNOSES REDACTED]. Review of facility form Weekly Fall Investigation Evaluation regarding Resident 11, identified with a Date of Fall of (MONTH) 7, (YEAR), revealed a written statement by Nursing Aide (NA 1) that Resident 11 was taken to bathroom- ambulated- walker one assist. Further review of the form revealed that Resident 11 lost her balance, that her fall was intercepted and she was lowered to the floor without injury. Review of Resident 11's care plans dated for (MONTH) 26, (YEAR), revealed that a revision was made to identified care area need regarding impaired physical ability. Further review of the associated interventions revealed for Transfer/Ambulation: transfers two assists with stand aid (a standing frame is assistive technology that can be used by a person who relies on a wheelchair for mobility) prn (as needed), 2 assist with RW (rolling walker) with w/c (wheelchair) to follow for ambulation. During interview with the Director of Nursing (DON) on (MONTH) 6, (YEAR), at 11:40 a.m. the DON confirmed that the revision to Resident 11's care plan for Transfer/Ambulation on (MONTH) 26, (YEAR), was the last revision prior to Resident 11 losing her balance on (MONTH) 7, (YEAR). During an interview with Nursing Home Administrator (NHA) on (MONTH) 6, (YEAR), NHA revealed the expectation that Resident 11's care plan for transfers/ambulation should have been followed. Review of the clinical record for Resident 28 on (MONTH) 4, (YEAR), at 1:00 p.m. revealed [DIAGNOSES REDACTED]. Review of Resident 28's quarterly MDS (Minimum Data Set- periodic assessment of a resident's functional capabilities) dated (MONTH) 6, (YEAR), revealed a BIMS score (brief Interview of Mental Status) of 14, indicating her cognitive status was intact. Review of Resident 28's care plan dated (MONTH) 16, (YEAR), states that Resident 28's left Darco shoe (shoe that provides protection of the foot after surgery or after trauma) should be worn for transfers, keep straps loose. Remove Darco shoe when Resident is sitting. During an observation of Resident 28 on the following dates and times (MONTH) 4, (YEAR), at 10:00 a.m., (MONTH) 5, (YEAR), at 11:00 a.m., and (MONTH) 6, (YEAR), at 9:30 a.m., revealed Resident 28 sitting in her wheelchair in her room with the Darco shoe on her foot. During an interview with Resident 28, on (MONTH) 6, (YEAR), at 9:30 a.m. she revealed that the Darco shoe is on her foot at all times when she is out of bed. During an interview with the Nursing Home Administrator on (MONTH) 6, (YEAR), at 2:00 p.m. she confirmed that the care plan should have been followed and the Darco shoe should be removed unless the resident is being transferred. 28 Pa. Code 211.11(a) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observation, review of select facility documents, and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety in the facility kitchen. Findings include: During entrance tour in the main facility kitchen on October 2, 2017, starting at 6: 20 a.m. while accompanied with facility Head Cook (HC 1) observation was made in walk-in refrigerator of a rack containing a tray with six pre-served individual dessert dishes of chocolate pudding, seven of vanilla pudding, and three of chocolate mousse. It was observed that there was no dating on either the individual dishes or the tray. Observation in the walk-in freezer during this same tour revealed an opened/partially used bag of shrimp (out of original case box) with no dating. Also observed were a plastic food storage bag (not original packaging) containing approximately two pounds of pizza sausage (out of original case box) with no labeling or dating (identified by HC 1), an unopened bag of stir fry vegetables (out of original case box) with no dating, a bag of spinach (out of original case box) with no dating or labeling, and an opened/partially used bag of peas (out of original case box) with no dating. Observation in the reach-in refrigerator during this same tour revealed an opened/partially used bag of whipped cream (out of original case box) with no dating and one container each of beef and chicken base opened/partially used (out of original case box) with no dating. During an interview with facility Dietary Manager (DM 1) on October 3, 2017, at approximately 12:45 p.m. DM 1 revealed that they had been having trouble with staff not dating and labeling foods. DM 1 revealed the expectation that foods should have an open and/or use by date and have a system in place. Request for facility policy/procedure for dating/labeling of food produced facility document titled Labeling and Dating for Households (resident living units where main facility food is received and then served to residents). Review of this document revealed the statements Use labels provided, Put name of product, Date prepared, Date to be discarded. During an interview with Nursing Home Administrator (NHA) on October 3, 2017, at 3:18 p.m. NHA revealed the expectation that food items should be dated as per policy. 28 Pa. Code 201.18 (b)(1) Management Previously cited 11/09/15

Based on observation, clinical record review and staff interview, it was determined that the facility failed to review the risks and benefits and obtained consent, complete assessments and perform measurements of bed rails prior to installation for seven of 16 residents reviewed (Resident 4, 6, 8, 9, 11, 12 and 13). Findings include: Review of the clinical record for Resident 4 revealed [DIAGNOSES REDACTED]. During an observation on October 3, 2017, at 9:15 a.m. revealed Resident 4 lying in bed with an enabler bar attached to the left side of her bed. Review of the clinical record revealed no assessment, measurements for risk of entrapment or consent for risk vs benefits of the enabler. During an interview with the Nursing Home Administrator (NHA) on October 3, 3017, at 3:03 p.m. she stated that the enabler bar is not considered a siderail therefore they do not to assessments, measurements or consents. Review of Resident 6's clinical record revealed [DIAGNOSES REDACTED]. Observation in Resident 6's room on October 4, 2017, at 10:30 a.m. revealed the presence of an enabler bar attached to the Resident's left side of her bed. Review of Resident 8's clinical record revealed [DIAGNOSES REDACTED]. Surveyor observation on October 2, 2017, at 11:10 a.m. and on October 3, 2017, at 10:35 a.m. revealed an enabler bar attached to the right side of Resident 8's bed. Review of the clinical record revealed no assessment, measurements for risk of entrapment or consent for risk vs benefits of the enabler. Review of Resident 9's clinical record revealed [DIAGNOSES REDACTED]. Surveyor observation on October 3, 2017, at 10:40 a.m. revealed Resident 9 sitting on the edge of the bed with bilateral enabler bars attached to the bed. Surveyor observation on October 3, 2017, at 1:30 p.m. revealed Resident 9 lying in bed with bilateral enabler bars attached to the bed. Review of the clinical record revealed no assessment, measurements for risk of entrapment or consent for risk vs benefits of the enabler. Review of Resident 11's clinical record revealed [DIAGNOSES REDACTED]. Observation in Resident 11's room on October 5, 2017, at 10:20 a.m. revealed the presence of bilateral side rails on her bed. During an interview with NHA on October 5, 2017, at approximately 11:15 a.m. NHA re-confirmed that her previous statement regarding the facility not doing assessments, measurements or consents for enabler bars also applied to Residents 6 and 11. Review of the clinical record for Resident 12 revealed [DIAGNOSES REDACTED]. Observation on October 5, 2017 at 8:48 a.m. revealed Resident 12 had an enabler bar attached to the right side of her bed. Review of Resident 13's clinical record revealed [DIAGNOSES REDACTED]. Surveyor observation on October 4, 2017, at 1:25 p.m. revealed an enabler bar attached to the left side of Resident 13's bed. Review of the clinical record revealed no assessment, measurements for risk of entrapment or consent for risk vs benefits of the enabler. During an interview with the Nursing Home Administrator (NHA) on October 3, 3017, at 3:03 p.m. she stated that the enabler bar is not considered a siderail therefore they do not to assessments, measurements or consents. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflects the residents' status for six of 15 resident records reviewed (Residents 2, 4, 6, 8, 12, and 13). Findings include: Review of Resident 2's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 2's quarterly Minimum Data Set assessment (MDS-an assessment tool utilized to identify residents' physical, mental, and psychosocial needs) dated July 18, 2016, revealed that section G (Functional Status) subpart G0120 A-B (Bathing) were not assessed and marked with dashes (-). Review of Resident 4's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 4's annual Minimum Data Set (MDS - assessment tool utilized to identify a residents' physical, mental, and psychosocial strengths and needs), dated April 29, 2016, revealed section G0110 Activities of Daily Living (ADL) Assistance, subsection G0120 A - Bathing self performance was coded with a - (dash) for the determination of bathing self-performance. Options for this section include 0 (independent), 1 (supervision), 2 (physical help limited to transfer only), 3 (physical help in part of bathing activity), 4 (total dependence), or 8 (activity itself did not occur .). Review of Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI - Instruction manual for coding of the MDS), dated [DATE], revealed that a - is not an appropriate code for MDS section G0120 A - Bathing self performance. During a staff interview on September 9, 2016, at approximately 11:15 a.m., Nursing Home Administrator revealed that the staff member that completed the MDS thought that it was acceptable to use, -. Nursing Home Administrator (NHA) revealed it is the facility's expectation that MDS assessments are accurately completed. Review of the clinical record for Resident 6 revealed [DIAGNOSES REDACTED]. Review of Resident 6's quarterly MDS dated [DATE], revealed Resident 6's height was measured to be 58 inches. Review of Resident 6's comprehensive MDS dated [DATE], revealed Resident 6's height was measured to be 55 inches. On September 8, 2016, the facility re-measured Resident and documented a correct height of 58 inches. During an interview on September 8, 2016, at 10:05 a.m. the NHA confirmed that the height on the comprehensive MDS was incorrect. Review of Resident 8's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 8's admission MDS dated [DATE], revealed Resident 8's height was measured to be 59 inches. Review of Resident 8's significant change MDS dated [DATE], revealed Resident 8's height was measured to be 64 inches. Review of Resident 8's quarterly MDS dated [DATE], revealed Resident 8 was measured to be 64 inches. On September 8, 2016, the facility re-measured Resident 8 and documented a correct height of 59 inches. During staff interview on September 9, 2016, at 11:10 a.m. the NHA revealed it is the facility's expectation that there would not be a height discrepancy on the MDS. Review of the clinical record for Resident 12 revealed [DIAGNOSES REDACTED]. Review of the Comprehensive MDS dated [DATE], of section O0250: Influenza Vaccine asks, Did the resident receive the influenza vaccine in this facility? was coded 0 - No. The reason stated why the Resident did not receive the flu vaccine was coded -. During an interview with the NHA on September 9, 2016, at 11:03 a.m. she stated that the answer to the question should have been coded 9 (none of the above). Review of clinical record for Resident 13 revealed [DIAGNOSES REDACTED]. Review of Resident 13's quarterly MDS dated [DATE], revealed section G0110 Activities of Daily Living (ADL) Assistance, C. Walk in room D. Walk in corridor (hallway), E. Locomotion on unit, F. Locomotion off unit, G. Dressing and J. Personal hygiene were all coded -. During an interview with NHA on September 9, 2016, at 11:05 a.m. she stated that the information should have been collected and recorded on the MDS. 28 Pa. Code 211.5 (g)(i) Clinical Records Previously Cited:10/21/2014

Based on clinical record review and staff interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical wellbeing resulting in death as a result of a wound infection for one of two residents reviewed (Resident 1). Findings include: Review of the clinical record for Resident 1 on August 11, 2016, at 10:00 a.m. revealed an admitted to the facility of May 10, 2016. Resident 1 was admitted with [DIAGNOSES REDACTED]. Review of the Resident 1's admission comprehensive Minimum Data Set assessment (MDS -a periodic assessment of resident needs) dated May 16, 2016, revealed a BIMS (Brief Interview of Mental Status) score of 0 out of 15 indicating that the resident is severely cognitively impaired (impairment of memory, orientation to person, time and place). Review of the admission nurses' notes and skin assessment dated [DATE], at 9:40 a.m. revealed that Resident 1's sacral area (the large, triangular shaped bone at the base of the spine) and coccyx area (the area commonly referred to as the tailbone) were intact (no areas of damage to the skin). Review of the progress notes dated June 17, 2016, at 2:45 p.m. revealed that Licensed Practical Nurse (LPN) 1 observed Resident 1 to have a superficial open area to the coccyx measuring 0.8 cm (centimeters-metric measurement 2.5 cm is equal to 1 inch in English measurement) x 0.1 cm x < (less than) 0.1 cm. Further review of the progress notes revealed that on June 20, 2016, the physician directed the staff to apply [MEDICATION NAME] Ointment (a smooth oily preparation that is used to protect and heal skin from irritations and to act as a moisture barrier). Review of the progress notes written by LPN 2 dated June 27, 2016, at 2:45 p.m. revealed that the area on the coccyx was showing no improvement and now measured 2.2 cm x 2.2 cm x < 0.1 cm. Review of the, Wound Report Assessment (a document used to track the progress or decline in a wound) dated June 27, 2016, by LPN 2 revealed that the coccyx wound had increased in size to 2.4 cm x 2.3 cm x 0.1 cm and that it was classified as a Stage II Pressure Ulcer (a ulcer involving loss of the top layers of the skin). The Wound Report Assessment also indicated that there was no odor and there was dark slough (dead tissue, usually cream or yellow in color) and scant serosanguinous drainage (blood and serum). Review of the progress note written by LPN 2 dated June 27, 2016, at 6:00 p.m. revealed an observation of the coccyx wound to measure 2.4 cm x 2.3 cm x 0.1 cm. Further review of the progress note revealed a new order for Santyl (an ointment that works by helping to break up and remove dead skin and tissue) to be applied to the wound bed, then to apply an Allevyn dressing (a highly absorbent [MEDICATION NAME] foam pad held between an adhesive perforated wound contact layer and a highly permeable outer top film). Review of the, Skin/Wound Tracking, (assessment of the wound) form dated July 1, 2016, revealed that the coccyx wound size was 2.7 cm x 4.0 cm x 0.1 cm. Review of the, Skin/Wound Tracking form dated July 4, 2016, revealed that the coccyx wound size was 3.2 cm x 4.0 cm x 0.2 cm. Review of the, Skin/Wound Tracking form dated July 5, 2016, revealed that the coccyx wound size was 3.2 cm x 4.0 cm x 0.2 cm. Review of the, Skin/Wound Tracking form dated July 6, 2016, revealed that the coccyx wound size was 3.2 cm x 4.0 cm x 0.2 cm Review of the, Skin/Wound Tracking form dated July 8, 2016 revealed that the coccyx wound size was 2.7 cm x 4.0 cm x 0.1 cm. Review of the progress notes written by LPN 2 dated July 11, 2016, at 8:00 p.m. revealed that the coccyx wound appeared to be larger and was starting to tunnel (a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation) at 6 o'clock and 2 o'clock (position based on a clock). The wound was described as gray/tan in color with slough (dead skin) covering the wound bed. The progress note indicated that the Registered Nurse was present to observe the wound. Review of the progress note written by Registered Nurse (RN) 1 on July 11, 2016, at 8:30 p.m. revealed an observation that Resident 1's wound was red, swollen and warm to the touch and the wound size measured 5 cm x 3.5 cm x 0.5 cm. Review of the progress note written by RN 1 dated July 11, 2016, at 8:30 p.m. revealed that there was a new physician's order for a wound consult regarding the status of Resident 1's coccyx wound. Review of the progress notes for July 16, 2016, at 5:30 a.m. revealed that Resident 1 had a temperature (increase in body temperature over a normal of 98.6 degrees Fahrenheit (F)) of 99.9 degrees F. Review of the progress notes for July 17, 2016, at 12:40 a.m. revealed that Resident 1 had a temperature of 101.3 degrees F at 12:20 a.m. An ordered medication via rectal suppository (Tylenol) was administered to decrease the temperature. The temperature was rechecked at 2:00 a.m. and was 100.3 degrees F. A third recheck of the temperature at 4:00 a.m. revealed a temperature of 99.0 degrees F. Review of the progress note written by RN 1 on July 17, 2016, at 12:10 p.m. revealed that the physician was informed about the increase in temperatures during the 11-7 shift (night shift) and of the increase in the yellow drainage and the foul odor that was noted during the sacral wound dressing change. A new order was provided by the physician to start Keflex (an antibiotic) to be administered by mouth, for the 10 days and to obtain a wound culture (a laboratory test from a sample of the wound to determine what germ was causing the infection). Review of the progress notes for July 18, 2016, at 4:20 a.m. revealed that Resident 1 had a temperature of 101.2 degrees F at 12:00 a.m. (midnight) and at 4:00 a.m. it was 99.4 degrees F after the administration of Tylenol. Review of the laboratory results for the white blood cell (WBC) counts (an indication of an infection) revealed that the WBC was 9.7 Units (x10^3 = units of measurement= number of white blood cells visualized by microscope in a designated amount of blood) on June 29, 2016, 12.6 Units on July 12, 2016 and 14.1 Units on July 18, 2016 (Normal range 3.8 to 11.0.) Review of the clinical record revealed that Resident 1 was transferred to the Wound Care Center for a consult on July 19, 2016, at 12:45 p.m. The Wound Care Physician documented that Resident 1 was totally unresponsive during a debridement (removal of dead tissue) of her coccyx wound. The recommendations to the facility were to provide a specialty mattress and to change the treatment to the coccyx wound by doing a wet to moist dressing daily after cleansing with a normal saline solution (a treatment where gauze is soaked in a normal saline solution (a 0.9 % salt and water solution) and applied to the wound). Review of the clinical record revealed that Resident 1's family had an interview with a Hospice service (a service to support people in end of life care) on July 20, 2016, and Hospice staff informed the facility staff that after the Keflex was completed on July 27, 2016, the family did not wish to give Resident 1 anymore antibiotics. The Hospice staff advised the facility staff on July 21, 2016, at 6:40 to discontinue all medications given by mouth except [MEDICATION NAME] (a narcotic pain medication) and [MEDICATION NAME] (an antianxiety medication). Review of all attending physician's orders dated for July 2016, revealed no physician order to discontinue the Keflex. Review of the Medication Administration Record [REDACTED]. A progress note from the Resident 1's attending physician dated July 22, 2016, stated that the sacral wound culture results that were obtained on July 17, 2016, grew [DIAGNOSES REDACTED] (a type of Gram-negative bacteria that can cause different types of healthcare-associated infections). In addition the physician informed the staff that the family does not want any aggressive treatment and documented, No antibiotics after Resident 1 is finished with the Keflex. A review of Resident 1's care plans failed to reveal that a care plan was developed for the wound to the coccyx. The review also failed to reveal that a care plan was developed for Hospice or palliative care. A review of the physician's plan of care for Hospice status revealed that it was signed on July 25, 2016, the date of Resident 1's death. Review of the death certificate for Resident 1 dated July 25, 2016, states the immediate cause of death [MEDICAL CONDITION] (an infection in the bloodstream) due to an infected wound of the sacrum (area which includes the coccyx at the end of the spine). During an interview with the Nursing Home Administration (NHA) on August 11, 2016, at 4:00 p.m. the NHA was unable to produce documentation that the family was notified of the results of the wound culture. The NHA confirmed that pressure ulcer and Hospice care plans should have been developed for Resident 1 by the facility. 28 Pa. Code 211.12(a)(c)(d)(2) Nursing services. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 11/9/15, 10/21/14. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/21/14.

Based on observation, clinical record review and staff interviews, it was determined that the facility failed to provide wound care designed to prevent pressure sore development and promote optimal healing for two of 2 residents reviewed (Residents 1 and 2) and resulting in death as a result of a wound infection for one of two residents reviewed (Resident 1). Findings include: Review of the clinical record for Resident 1 on August 11, 2016, at 10:00 a.m. revealed an admitted to the facility of May 10, 2016. Resident 1 was admitted with [DIAGNOSES REDACTED]. Review of the Resident 1's admission comprehensive Minimum Data Set assessment (MDS -a periodic assessment of resident needs) dated May 16, 2016, revealed a BIMS (Brief Interview of Mental Status) score of 0 out of 15 indicating that the resident is severely cognitively impaired (impairment of memory, orientation to person, time and place). Review of the admission nurses' notes and skin assessment dated [DATE], at 9:40 a.m. revealed that Resident 1's sacral area (the large, triangular shaped bone at the base of the spine) and coccyx area (the area commonly referred to as the tailbone) were intact (no areas of damage to the skin). Review of the progress notes dated June 17, 2016, at 2:45 p.m. revealed that Licensed Practical Nurse (LPN) 1 observed Resident 1 to have a superficial open area to the coccyx measuring 0.8 cm (centimeters-metric measurement 2.5 cm is equal to 1 inch in English measurement) x 0.1 cm x < (less than) 0.1 cm. Further review of the progress notes revealed that on June 20, 2016, the physician directed the staff to apply [MEDICATION NAME] Ointment (a smooth oily preparation that is used to protect and heal skin from irritations and to act as a moisture barrier). Review of the progress notes written by LPN 2 dated June 27, 2016, at 2:45 p.m. revealed that the area on the coccyx was showing no improvement and now measured 2.2 cm x 2.2 cm x < 0.1 cm. Review of the, Wound Report Assessment (a document used to track the progress or decline in a wound) dated June 27, 2016, by LPN 2 revealed that the coccyx wound had increased in size to 2.4 cm x 2.3 cm x 0.1 cm and that it was classified as a Stage II Pressure Ulcer (a ulcer involving loss of the top layers of the skin). The Wound Report Assessment also indicated that there was no odor and there was dark slough (dead tissue, usually cream or yellow in color) and scant serosanguinous drainage (blood and serum). Review of the progress note written by LPN 2 dated June 27, 2016, at 6:00 p.m. revealed an observation of the coccyx wound to measure 2.4 cm x 2.3 cm x 0.1 cm. Further review of the progress note revealed a new order for Santyl (an ointment that works by helping to break up and remove dead skin and tissue) to be applied to the wound bed, then to apply an Allevyn dressing (a highly absorbent [MEDICATION NAME] foam pad held between an adhesive perforated wound contact layer and a highly permeable outer top film). Review of the, Skin/Wound Tracking, (assessment of the wound) form dated July 1, 2016, revealed that the coccyx wound size was 2.7 cm x 4.0 cm x 0.1 cm. Review of the, Skin/Wound Tracking form dated July 4, 2016, revealed that the coccyx wound size was 3.2 cm x 4.0 cm x 0.2 cm. Review of the, Skin/Wound Tracking form dated July 5, 2016, revealed that the coccyx wound size was 3.2 cm x 4.0 cm x 0.2 cm. Review of the, Skin/Wound Tracking form dated July 6, 2016, revealed that the coccyx wound size was 3.2 cm x 4.0 cm x 0.2 cm Review of the, Skin/Wound Tracking form dated July 8, 2016 revealed that the coccyx wound size was 2.7 cm x 4.0 cm x 0.1 cm. Review of the progress notes written by LPN 2 dated July 11, 2016, at 8:00 p.m. revealed that the coccyx wound appeared to be larger and was starting to tunnel (a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation) at 6 o'clock and 2 o'clock (position based on a clock). The wound was described as gray/tan in color with slough (dead skin) covering the wound bed. The progress note indicated that the Registered Nurse was present to observe the wound. Review of the progress note written by Registered Nurse (RN) 1 on July 11, 2016, at 8:30 p.m. revealed an observation that Resident 1's wound was red, swollen and warm to the touch and the wound size measured 5 cm x 3.5 cm x 0.5 cm. Review of the progress note written by RN 1 dated July 11, 2016, at 8:30 p.m. revealed that there was a new physician's orders [REDACTED]. Review of the progress notes for July 16, 2016, at 5:30 a.m. revealed that Resident 1 had a temperature (increase in body temperature over a normal of 98.6 degrees Fahrenheit (F)) of 99.9 degrees F. Review of the progress notes for July 17, 2016, at 12:40 a.m. revealed that Resident 1 had a temperature of 101.3 degrees F at 12:20 a.m. An ordered medication via rectal suppository (Tylenol) was administered to decrease the temperature. The temperature was rechecked at 2:00 a.m. and was 100.3 degrees F. A third recheck of the temperature at 4:00 a.m. revealed a temperature of 99.0 degrees F. Review of the progress note written by RN 1 on July 17, 2016, at 12:10 p.m. revealed that the physician was informed about the increase in temperatures during the 11-7 shift (night shift) and of the increase in the yellow drainage and the foul odor that was noted during the sacral wound dressing change. A new order was provided by the physician to start Keflex (an antibiotic) to be administered by mouth, for the 10 days and to obtain a wound culture (a laboratory test from a sample of the wound to determine what germ was causing the infection). Review of the progress notes for July 18, 2016, at 4:20 a.m. revealed that Resident 1 had a temperature of 101.2 degrees F at 12:00 a.m. (midnight) and at 4:00 a.m. it was 99.4 degrees F after the administration of Tylenol. Review of the laboratory results for the white blood cell (WBC) counts (an indication of an infection) revealed that the WBC was 9.7 Units (x10^3 = units of measurement= number of white blood cells visualized by microscope in a designated amount of blood) on June 29, 2016, 12.6 Units on July 12, 2016 and 14.1 Units on July 18, 2016 (Normal range 3.8 to 11.0.) Review of the clinical record revealed that Resident 1 was transferred to the Wound Care Center for a consult on July 19, 2016, at 12:45 p.m. The Wound Care Physician documented that Resident 1 was totally unresponsive during a debridement (removal of dead tissue) of her coccyx wound. The recommendations to the facility were to provide a specialty mattress and to change the treatment to the coccyx wound by doing a wet to moist dressing daily after cleansing with a normal saline solution (a treatment where gauze is soaked in a normal saline solution (a 0.9 % salt and water solution) and applied to the wound). Review of the death certificate for Resident 1 dated July 25, 2016, states the immediate cause of death [MEDICAL CONDITION] (an infection in the bloodstream) due to an infected wound of the sacrum (area which includes the coccyx at the end of the spine). The facility failed to provide wound care designed to prevent pressure sore development and promote optimal healing for Resident 1 and resulting in a wound infection as the cause of death. Review of the clinical record on August 11, 2016, at 8:30 a.m. revealed that Resident 2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 2's annual Minimum Data Set assessment (MDS - a periodic assessment of resident needs) dated July 18, 2016, revealed a BIMS (Brief Interview of Mental Status) score of 0 out of a possible 15, indicating that the resident was severely cognitively impaired. The staff assessment of the resident's mental status revealed that his/her daily decision making status required modification to perform tasks of daily life which he/she was unable to perform independently due to his/her memory, orientation, and recall impairments. Review of Resident 2's Treatment Medication Record (form used to document when a treatment was completed by a licensed nurse that is ordered by a physician) revealed an order for [REDACTED].>Observation of the daily wound care for Resident 2 observed on August 11, 2016, at 9:30 a.m. provided by Licensed Practical Nurse (LPN) 1, revealed that LPN 1 positioned the resident onto her side and informed the resident he/she would have to hold onto the rail to stay in position for her wound care. LPN 1 came to the opposite side of the bed and pulled the resident's slacks down to his/her upper thigh area then opened her brief on one side and pulled it down at an angle over the resident's slacks. The brief was soiled with serosanguinous (drainage consisting of blood and serum) drainage. During the wound care observation, hand hygiene was only observed at the beginning of the procedure and at the end of the procedure. Gloves were applied after washing the hands initially. The serosanguinous soiled dressing was removed and placed into the regular trash can in Resident 2's room. LPN 1 then pulled a cotton tipped applicator (a large Q-tip) from the stock supply bag utilizing her soiled gloves. She removed five strips of packing from Resident 2's wound on separate attempts and utilized the same soiled gloved hands to obtain cotton tip applicators from the stock supply bag each time. All of the drainage soiled packing strips were placed in the regular trash can in Resident 2's room. LPN 1 then removed her gloves and placed them in the trash can and proceeded to reapply another pair of gloves without performing hand hygiene. A 4 inch by 4 inch gauze was obtained and normal saline (a 0.9 per cent salt and water solution) was used to cleanse the wound. After cleansing the wound and dabbing the skin surface to dry the area, LPN 1 attempted to insert a corner of the gauze to dry the entrance of the wound. LPN 1 then obtained one 4 inch by 4 inch gauze and opened it lengthwise, to form into a strip, saturated it with normal saline and packed it into the wound. LPN 1 labeled and applied the cover dressing, closed the resident soiled brief, pulled up her slacks, repositioned her, covered her with a blanket, handed the resident her bed control, lowered the bed, and then removed her gloves and threw the gloves in the regular trash. LPN 1 then washed her hands and picked up the bin containing the stock cotton tipped applicators and the unused normal saline bullets (salt solution in a plastic dispenser) and left the room. The surveyor asked LPN 1 if she was finished in the room, and she stated, Yes. The trash can containing the soiled dressing was not taken to the biohazard (medically used trash contaminated with blood or other infectious materials) trash. During an interview with LPN 1 on August 11, 2016, at 9:50 a.m. following the wound care observation, the surveyor asked her about the location of the biohazard trash can. LPN 1 said she forgot to take the soiled drainage trash bag to the biohazard can in the soiled utility room as was expected. When questioned about the frequency of hand hygiene, she stated that she should have washed her hands during the procedure. LPN 1 was asked about the removal of the five packing strips from the wound and the fact that she only replaced one strip. She stated she was unsure why there were five strips in the wound. An interview with the Wound Care Physician on August 11, 2016, at 1:25 p.m. revealed that he will have to clarify his orders for the staff to utilize one continuous piece of packing strip because he found three packing strips left in the resident at her last visit to his office on August 4, 2016. Review of the facility's, Biohazard/ Infectious Waste policy on August 11, 2016, revealed that all blood-soiled dressings are potentially infectious and are required to be placed in a red biohazard bag and then placed into the red biohazard container in the soiled utility room. An interview with the Nursing Home Administrator and the Director of Nursing on August 11, 2016, at 4:00 p.m. confirmed the expectation that hand hygiene should be performed after removing the soiled dressing and before applying the clean dressing, that soiled drainage dressings should be placed in the biohazard trash and that staff need to be aware of separate pieces of packing that were placed so that none are missed during the dressing change. 28 Pa. Code 211.12(a)(c) Nursing services. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 11/9/15, 10/21/14. 28 Pa. Code 211.12(d)(3)(5) Nursing services. Previously cited 10/21/14. 28 Pa. Code 211.10(a) Resident care policies. Previously cited 10/21/14. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.5(f) Clinical records. Previously cited 10/21/14. 28 Pa. Code 201.18(e)(1) Management. Previously cited 10/21/14.

Based on observations, review of facility policy, and interviews with staff, it was determined that the facility failed to provide ongoing assessments and monitoring for a decline in physical functioning for one of 13 residents (Resident R12) reviewed for assessment. Findings include: Review of the facility policy "Nursing-Nursing Responsibilities" updated April 12, 2011, revealed that Nursing Assistants should report to the Staff Nurse/Charge Nurse any change in a resident's condition. The Staff Nurse/Charge Nurse shall document pertinent resident information in the electronic data system as applicable and/or in the residents' medical record. Staff/Charge Nurse (licensed staff) shall notify the physician and responsible agent of any significant change in a resident's condition. The Charge Nurse Job Description, last updated July 15, 2011, revealed that they are to notify the physician, when necessary, of changes in resident's condition and implement the physician's orders in a timely manner. Review Resident R12's clinical record revealed that she was admitted from the hospital back to Chapel Pointe via ambulance transport at 3:30 p.m. on September 12, 2011, after having left hip surgery to repair a fracture (ORIF). The vital signs on the transport sheet were Temp (temperature) 98 degrees Fahrenheit, Pulse 74 beats per minute, respirations 20 breaths per minute, and oxygen saturation (measurement of oxygen in the blood) was 98 percent on 5 L/min (liters per minute). The discharge instructions from the hospital indicated to notify the physician if the resident experienced any of the following: Difficulty breathing/noisy respirations. New onset of rapid breathing. Shortness of breath. Increased pain/redness/swelling at incision. Worsening symptoms. Temperature greater than 100 degrees Fahrenheit. At the time of her admission, on September 12, 2011, the nurse's notes revealed that at 3:30 p.m., Resident R12's vitals were Temp 98 degrees Fahrenheit, Pulse 90 beats per minute, Respirations 22 breaths per minute, and blood pressure 195/96. Her oxygen saturation was 94 percent at 2 L/min via nasal cannula (oxygen tubing to the nose). She had mild confusion at that time. (Her most recent BIMS (Brief Interview for Mental Status) score was 15/15 in her quarterly review on 8/26/11). Her skin condition was also reviewed and documented scars, bruises, and incisions. At 4:10 p.m., the nurse's documentation indicated that Resident R12 was alert but confused, her color was pale, skin warm and dry, and lung sounds diminished with basal crackles. Her oxygen saturation was 92 percent with a slash over the two and a four written on top of it with no initialing. Her oxygen was still by nasal cannula. The incision on her left hip and other areas of bruising were also described. There was no other documentation in the nurse's notes or in chart until 6:25 p.m. indicating that Resident R12 became very short of breath and diaphoretic (sweaty). Her oxygen saturation had dropped to 82 percent on 2L/min oxygen. The oxygen was raised to 4 L/min via facemask. A [MEDICATION NAME] (respiratory treatment by Nebulizer) was also given. Her vitals at that time were Temp 98 degrees Fahrenheit, blood pressure was 198/96, pulse was 98 beats per minute, and respirations were 36 breaths per minute, rapid and labored. Again, there was no other documentation in the nurse's notes or in the chart until 6:40 p.m. when the note revealed that Resident R12 had moist lung sounds with audible inspiratory and expiratory wheezes using accessory muscles. No improvement in her respirations but oxygen saturation had gone back up to 92 percent. The note revealed that the resident was agitated and fearful. The Physician was notified and ordered the facility to transfer the resident to the hospital. At 6:45 p.m., the emergency transport was called to transport Resident R12 to the hospital. At 6:50 p.m., the "POA (power of attorney) was called...no reply." At 6:52 p.m., the emergency transport arrived and was stabilizing the resident. At 7:00 p.m., Resident R12 was transported to the hospital via ambulance. At 7:05 p.m. the second POA was notified and "message left." At 7:45 p.m., the doctor called the facility to inform them that Resident R12 had passed away during the transport into the emergency room at the hospital. During an interview with the Charge Nurse (RN1) on September 15, 2011, at 1:00 p.m., she indicated that things didn't actually happen the way it was documented in the nurse's notes. She stated that the Nurse Aide was with the resident originally and that the nurse aide went to get the Licensed Practical Nurse to report a change in Resident R12's condition. The Licensed Practical Nurse assessed the resident and then came to her (RN1). RN1 indicated that she increased the oxygen to 4 liters per minute via facemask. She said she then called the doctor and got an order for [REDACTED]. Interview with the Director of Nursing on September 15, 2011, at 1:15 p.m. revealed that she was there that night and the verbal report to her from RN 1 sounded like everything was done timely; however, when she reviewed the actual nurse's notes, she indicated that there was missing assessment documentation and physician orders. She stated that she would expect her staff to follow their job descriptions and to follow the facility policy for Nursing Responsibilities. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. Previously cited 10/28/10 and 8/11/11 28 Pa. Code: 211.10 (c) Resident care policies. Previously cited 10/28/10 and 8/11/11 28 Pa. Code: 211.12 (d)(3) Nursing services. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services. Previously cited 8/11/11