Every finding on record at Concordia at Arbutus Park

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to afford residents the right of self-determination to make choices for one of three residents reviewed (Resident R2).Findings include:A facility policy for Resident Rights dated January 16, 2026, indicated that the resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights. The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: the resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. An annual Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated February 2, 2026, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had a diagnosis that included Alzheimer's disease. Care plan for Resident 2 dated February 23, 2026, included that the resident was at risk for falls or injury related to falls, and she had an intervention that was active through March 6, 2026, that indicated the resident was to have a special lock to her bedroom door. Physician's orders for Resident 2 dated November 25, 2025, indicated that the resident was to have a door lock block to her room door when she was out of her room. Review of the Treatment Administration Record (TAR) for Resident 2 dated December 2025, January 2026, February 2026, and March 2026, revealed documented evidence that the resident had a door lock block to her room door when she was out of her room every shift in December, January and February, and through March 4, 2026. Observation of the door lock block used for Resident 2's door on April 8, 2026, at 1:12 p.m. revealed that it was a wooden block that was placed on a door where the door handle is, that prevented the door handle from being pushed in and thus preventing the door from being opened. There was a bolt and pin device on the bottom of it that prevented it from being easily removed from the door. Interview with Licensed Practical Nurse 1 at the time of this observation revealed that the Resident's son provided the facility with the bolt/pin lock for the wood block believing it was an improvement to what the facility had. She reported that the resident occasionally attempted to get into her room when the block was in place, and she was easily redirected. Interview with Nurse Aide 2 on April 8, 2026, at 2:05 p.m. revealed that a device was previously used on Resident 2's bedroom door that prevented her from entering her room. It was never used when anyone was in that room, and it did not interfere with the roommate having access to the room whenever she wanted because she was not independent with mobility and needed assistance to get to her room. Interview with Licensed Practical Nurse 3 on April 8, 2026, at 2:08 p.m. revealed that a door lock was previously used on Resident 2's room door to prevent her from being unsupervised in her room. The Resident's son requested that the lock be put on the door block. She was uncertain exactly how long the door block lock was in place, but did reveal that while the block was in place, the resident would make attempts to enter her room and staff would redirect her by telling her that someone was cleaning her room, or they would get her personal effects like her purse that she was looking for. The door block was never used when anyone was in the room, and it did not prevent that resident's roommate from having less access to her room than she normally had. Interview with the Director of Nursing on April 8, 2026, at 2:33 p.m. revealed that the Resident's son insisted on keeping the resident out of her room believing he could prevent all falls, and he bought a special lock for the wood block the facility had that was primarily used in the past to secure resident belongings when they went to the hospital. They allowed the door lock to be put on the door, which prevented the Resident from accessing her room whenever she wanted. The Director of Nursing revealed that she felt bad that it prevented the Resident from going into her room and removed that door lock block at the resistance of the Resident's son. 28 Pa. Code 201.29(a) Resident Rights.

Based on a review of a list of nurse aides currently employed by the facility, including their hire dates and training hours, as well as staff interviews, it was determined that the facility failed to ensure that nurse aides had 12 hours of in-service training annually for two of five nurse aides reviewed (Nurse Aides 7 and 8). Findings include:A list of nurse aides provided by the facility revealed that based on their months and days of hire: Nurse Aide 7 should have received at least 12 hours of in-service training between February 23, 2024, and February 23, 2025. However, there was no documented evidence that she received at least 12 hours of in-service training as required. Nurse Aide 8 should have received at least 12 hours of in-service training between April 25, 2024, and April 25, 2025. However, there was no documented evidence that she received at least 12 hours of in-service training as required. Interview with the Nursing Home Administrator on August 20, 2025, at 3:45 p.m. confirmed that there was no documented evidence that the above nurse aides received at least 12 hours of in-service training as required. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.19(7) Personnel Policies and Procedures.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received proper care for indwelling urinary catheters (a thin, flexible tube inserted into the bladder to drain urine from the bladder) for one of 36 residents reviewed (Resident 1) and failed to ensure that urinary output was monitored for one of 36 residents reviewed (Resident 44) who had an indwelling urinary catheter. Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated June 26, 2025, revealed that the resident was cognitively intact, required extensive assistance with most daily care needs, had a Foley catheter (a thin tube inserted into the bladder to allow urine drainage), and had diagnosis that included a pressure ulcer to the sacral region. Physician's orders dated June 20, 2025, indicated that Resident 1 was to have a 16 French catheter with a 30 ml (milliliter) balloon (an inflatable balloon that helps keep that catheter inside the bladder), routine change every 56 days related to a pressure area to the coccyx/sacrum. Urinary committee notes for Resident 1, dated June 23, 2025, indicated the resident now has a foley catheter in place due to a pressure sore impacted by urinary incontinence. A care plan for Resident 1's indwelling catheter, revised on June 24, 2025, indicated that the catheter was placed for a stage 4 pressure area affected by urinary incontinence, and that the urinary drainage tubing/bag should be changed at least twice a month, on the fifth and nineteenth of every month, or whenever necessary. A review of the resident's clinical record, including progress notes, treatment administration record's and a review of a treatment log notebook kept at the nurses station, did not indicate that the catheter drainage tubing/bag was changed on July 5 and 15, and August 5, 2025. Interview with Registered Nurse Supervisor 6 on August 21, 2025, at 9:35 a.m. revealed that it is standard practice for their facility to change the foley catheter drainage bag on the fifth and fifteenth of every month. She further indicated that there is no documentation in Resident 1's treatment administration record to indicate that the drainage bags were changed. Interview with the Director Of Nursing on August 21, 2025, at 11:58 a.m. confirmed that it is part of the facility's protocol to change the foley drainage bag twice a month and that she feels certain that it was done. However, there was no documented evidence that Resident 1's foley drainage bag was changed on July 5, 19 or August 5, 2025, as care planned, and it should have been. The facility's policy regarding intake and output documentation, dated January 16, 2025, indicated that foley output is to be documented in point of care, under the foley output task button. A quarterly MDS assessment for Resident 44, dated June 4, 2025, revealed that the resident was cognitively impaired, and had an indwelling urinary catheter. A care plan for the resident, dated May 6, 2024, revealed that the resident had a suprapubic catheter (a flexible tube that drains urine from the bladder through the abdomen), and his catheter bag was to be emptied, and the output measured every shift. Review of Resident 44's clinical record for March, April, May, June, July and August, 2025, revealed that there was no documented evidence that the resident's urinary output was measured on the following dates and shifts: May 19 and 25, June 9 and 27, July 8 and August 1 and 18 on the day shift; March 10 and 12, April 6, 12 and 29, May 6, 7, 9, 10, 13, 15 and 25, June 24 and 27, July 1, 21, 22, 27, 30 and 31, and August 2, 3, 4, 8, 15, 16, and 17 on the evening shift; and March 31, April 29 and 30, May 31, June 30 and July 27 and 31 on the night shift. Interview with the Director of Nursing on August 20, 2025, at 11:41 a.m. confirmed that there was no documented evidence that Resident 44's urinary output was measured as per facility policy and per the resident's care plan on the above-mentioned dates and shifts. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a Nurse Aide Registry verification for one of two nurse aides reviewed (Nurse Aide 1), failed to conduct a criminal background check on one of two nurse aides reviewed (Nurse Aide 2), and failed to ensure that the status of nursing licenses was checked with the State Board of Nursing for two of two registered nurses reviewed (Registered Nurse 3 and Registered Nurse 4).Findings include:The facility's abuse policy, dated January 16, 2025, indicated that the facility will screen potential employees for a history of abuse, neglect, or mistreating residents. If employment references cannot be obtained, personal references may be obtained. State licensure and certification agencies, and applicable registries will be contacted prior to employment to validate current licensure or certification requirement and to determine if the potential employee is in good standing with the registry and potential employees will have a criminal background check completed at time of selection as required.The personnel file for Nurse Aide 1 revealed a hire date of June 30, 2025. However, there was no documented evidence that her standing on the Pennsylvania State Nurse Aide Registry was verified, and there was no documented evidence that reference checks from previous or current employers were obtained prior to the employees' start date. The personnel file for Nurse Aide 2 revealed a hire date of June 11, 2025. However, there was no documented evidence that her criminal background check was completed prior to the employees' start date. The personnel file for Registered Nurse 3 revealed a hire date of July 22, 2025. However, there was no documented evidence that her license was checked with the Pennsylvania State Board of Nursing, and there was no documented evidence that reference checks from previous employers were obtained prior to the employees' start date.The personnel file for Registered Nurse 4 revealed that a hire date of August 6, 2025. However, there was no documented evidence that her license was checked with the Pennsylvania State Board of Nursing prior to the employees' start date.Interview with the Nursing Home Administrator on August 20, 2025, 3:45 p.m. confirmed that there was no documented evidence to indicate that registry verification with the Pennsylvania State Nurse Aide Registry, licensure verification with the Pennsylvania State Board of Nursing, criminal background checks and reference checks from previous employers were completed prior to dates of hire for the above-mentioned nursing staff and there should have been. 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(e)(1) Management.

Based on review of clinical records, as well as staff and resident interviews, it was determined that the facility failed to follow physician's orders for one of 36 residents reviewed (Resident 14). Findings include:An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated June 3, 2025, revealed that the resident was cognitively intact, required assistance with care needs, used oxygen, received hospice services and had diagnoses that included chronic obstructive pulmonary disease (COPD) (chronic lung disease making breathing difficult), chronic respiratory failure (blood does not have enough oxygen and causes difficulty breathing), and end stage heart failure (the heart is unable to pump enough blood to meet the body's needs).Physician's orders for Resident 14, dated July 13, 2025, included orders for the resident to receive one puff/inhalation of Trelegy Ellipta inhaler 200-62.5-25 micrograms (mcg) daily in the morning with instructions that the resident may keep the medication at the bedside for unsupervised self-administration.Observations during medication administration for Resident 14 on August 20, 2025, at 8:16 a.m. revealed that the resident did not have his Trelegy inhaler for administration. Licensed Practical Nurse 5 confirmed that the Trelegy inhaler was ordered on August 6, 2025, and the facility was waiting for the inhaler to be delivered.Interview with Resident 14 on August 20, 2025, at 8:40 a.m. revealed that he has not had his Trelegy inhaler for about two weeks. He reported that he had taken the medication for about 10 years and had been more short of breath since it has not been available to self-administer. Review of Resident 14's Medication Administration Record (MAR) for August 2025, revealed that the Trelegy Ellipta inhaler was coded U-SA for unsupervised self-administration. There was no documented evidence that the facility attempted to follow up with the pharmacy or the physician related to medication not being received.Interview with the Director of Nursing on August 20, 2025, at 2:43 p.m. indicated that she was not aware that the resident had not had his Trelegy inhaler. She indicated that she had received a notice from pharmacy, dated August 19, 2025, that indicated they cancelled the Trelegy inhaler due to the facility's account requiring Omnicare to obtain approved authorization prior to dispensing the medication and that the drug exceeded the facility's high dollar limit which required approval. She indicated that hospice should have covered that medication since he was on hospice for COPD and that she was checking with hospice regarding coverage for the future.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policies, observations, and staff interviews, it was determined that the facility failed to ensure that food stored in the kitchen was dated once opened, discarded after the use by date and discarded after the manufacturer's expiration date.Findings include: The facility policy regarding food labeling and dating, dated January 16, 2025, revealed that all food items must be labeled and dated to ensure foods are being used in the proper timeframe. Twice daily the dining services manager on duty will check all perishables for proper covering, labeling and dating. Any perishables needing to be discarded will be discarded. Any unopened food or beverage item will be discarded by the manufacturer labeled expiration date. Observations in the kitchen refrigerator on August 18, 2025, at 9:05 a.m. revealed a package of pre-sliced bologna and ham wrapped in plastic wrap and dated August 10, 2025, with a discard date of August 15, 2025. Observations in the kitchen's walk-in refrigerator used for milk on August 18, 2025, at 9:15 a.m. revealed an opened gallon container of vanilla milk shake/ice cream mix dated as packaged on August 1, 2025, and received on August 12, 2025. The gallon container of vanilla milk shake/ice cream mix was not dated when opened and had no manufacturer's expiration date. Observations in the kitchen's walk-in refrigerator used for milk on August 20, 2025, at 11:27 a.m. revealed three unopened iced coffees that were stamped with the use by date of August 18, 2025. Interview with the Dietary Supervisor at the time of the observations confirmed that the pre-sliced bologna and ham should have been discarded, the gallon container of vanilla milk shake/ice cream mix should have been dated when opened and the unopened iced coffees should have been discarded after the use by date. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that the physician's request to be contacted the following day for a status report after a change in condition for one of five residents reviewed (Resident 1).Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 16, 2025, revealed that the resident was cognitively impaired and required assistance with daily care needs. A nursing note dated December 25, 2024, at 8:28 p.m. that documented a secure conversation with the physician, revealed that Resident 1 had a coughing fit (a sudden, often violent and uncontrollable, bout of coughing that can be exhausting and painful) after drinking a cup of water with her bedtime medications. It was reported that Resident 1's vital signs were within normal limits and she had no adventitious lung sounds (abnormal sounds heard during auscultation). The physician was asked if he would like a chest x-ray in the coming days. The physician's response on December 25, 2024, at 8:30 p.m. was to monitor and see how she does and decide in the morning if a chest x-ray would be ordered.Review of Resident 1's medical record for December 2024, revealed that there was no documented evidence that the facility contacted the physician the following day for a status report after a change in condition per his request on December 25, 2024.Interview with the Director of Nursing on July 1, 2025, at 12:35 p.m. confirmed that the physician was not contacted the following day for a status report after a change in condition per his request and he should have been. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies, clinical records, and facility reports, as well as observations and staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards for one of four residents reviewed (Resident 1). This deficiency was cited as Past Non-Compliance. Findings include: The facility's policy regarding residents who wander, dated January 16, 2025, indicated that the residents in the facility will be provided with a safe environment in which to live. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 5, 2024, indicated that the resident was usually understood and could usually understand others, did not have any wandering behaviors, required supervision with ambulating, and had diagnosis that included Alzheimer's dementia. A care plan intervention for Resident 1, dated April 12, 2024, indicated that the resident was independent with a front-wheeled walker on the unit. A care plan for Resident 1, dated March 25, 2025, indicated that the resident was at risk for injury from falls and included an intervention, dated March 27, 2025, through April 2, 2025, that the resident was to have a door alarm in use. A wandering risk assessment for Resident 1, dated March 26, 2025, indicated that the resident was at moderate risk for wandering, that the resident's family requested a room change, and that the resident comes out of her new room and needs redirected as she is looking for the lobby and dining room on the other unit. She was found in the hall by the offices near the fax room and was easily redirected. A door alarm was to be placed on the door to alert staff if she leaves her room. A risk and environmental safety assessment for Resident 1, dated March 27, 2025, indicated that a new safety intervention was implemented that included a door alarm on the resident's room. An incident note for Resident 1, dated March 30, 2025, at 10:30 p.m. revealed that a staff member received a phone call reporting that Resident 1 was observed outside near the smoke shed. Nurse aides found the resident outside with her front-wheeled walker. After receiving the call, the registered nurse went back to check the resident's room and noted that the door alarm was off. Two licensed practical nurses brought the resident back to the nursing unit and Resident 1 was then provided a room on the Crossroads dementia unit for her safety, as she was a flight risk. A security bracelet was placed on Resident 1 and nursing administration was notified. An incident investigation for Resident 1, dated March 30, 2025, revealed that Resident 1 was assisted to her room by Licensed Practical Nurse 1. When License Practical Nurse 1 left the resident's room, she did not turn the door alarm on as care planned. The resident later exited her room, went through a door leading to the chapel that should have alarmed and did not, and through the door to exit the facility, which should have alarmed but did not. The facility was notified at around 10:30 p.m. that Resident 1 was observed outside the facility near the smoke shed. Review of a preventative maintenance log, dated 2025, revealed that monthly door alarm battery replacement was to be completed and documented; however, there was no document evidence that door alarm batteries were checked or replaced in 2025 until March 31. Interview with the Director of Nursing on April 9, 2025, at 2:40 p.m. confirmed that the door alarm on Resident 1's door was not turned on as care planned, the alarm on the interior door leading to the chapel was functioning properly, and the double doors on the left before entering the chapel that lead outside was not functioning properly due to the batteries being dead. This resulted in the resident being able to leave the facility undetected. The Director of Nursing also confirmed at this time that there was no documented evidence that monthly maintenance inspections of the batteries in the battery-operated door alarms were checked in January or February 2025, and were not checked in March until after the incident occurred. Following the incident on March 30, 2025, the facility's corrective actions included: Resident 1 was returned to her previous room on the Crossroads secured unit and a security bracelet was applied to alert staff of attempts to exit that unit. Licensed Practical Nurse 1, who failed to activate the door alarm on Resident 1's door, was given a two-day unpaid suspension for failing to follow established safety protocols. A review of the facility's plan of correction revealed that education was provided to staff regarding prevention of abuse and/or neglect, review of the policy for safety risks, and the staffs' responsibilities regarding changes in resident care plans related to safety interventions. Maintenance staff was educated on the importance of monitoring, testing, and monthly preventative maintenance including battery replacement on all alarmed doors. A review of the facility's plan of correction revealed all staff were informed of what doors had battery-operated door alarms and daily inspections of the battery-operated door alarms was being completed. Interviews with staff throughout the facility during the on-site investigation revealed that they were knowledgeable about the functioning of the facility's door alarms and identifying changes in the residents' safety risk interventions. A review of the facility's corrective actions revealed that they were in compliance with F689 on April 2, 2024. Interview with the Director of Nursing on April 9, 2025, at 3:00 p.m. revealed staff education was completed, and ongoing review of the incident was to be discussed during the monthly Quality Assurance (QA) meeting. 28 Pa. Code 211.10(d) Resident Care Policies. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on observations and staff interviews, it was determined that the facility failed to ensure that residents had a clean and homelike environment on one of three nursing units (secured unit). Findings include: Observations on September 16, 2024, at 8:17 p.m. revealed that the carpet in the hallway on the 400 side of the secured unit was stained and dirty. There was duct tape on the carpet of the threshold between the hallway and room [ROOM NUMBER] and between the hallway and room [ROOM NUMBER]. Interview with the Director of Maintenance on September 18, 2024, revealed that the carpet in the secured unit was to be scrubbed nightly and that it was in need of being replaced. He stated that the duct tape on the floor between the hallway and rooms [ROOM NUMBERS] was there because the strip that was there was a trip hazard. He stated that the duct tape made a smooth transition between the hallway and the resident rooms. Interview with the Director of Nursing on September 18, 2024, at 1:24 p.m. confirmed that the carpeting in the secured unit needed replaced and that duct tape should not have been placed on the threshold between the hallway and the resident rooms. 28 Pa. Code 201.29(j) Resident Rights. 28 Pa. Code 207.2(a) Administrator's Responsibility.

Based on facility policies, observations, and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety. Findings include: The facility's policy regarding labeling and dating food, dated [DATE], revealed that food was to be discarded on or immediately after the expiration/use by date. Observations in the kitchen on [DATE], at 6:15 p.m. revealed that there were two gallons of chocolate ice cream mix that expired [DATE], and one gallon of vanilla ice cream mix that expired [DATE], in the cooler. Observations in the freezer at that time revealed two bags of frozen chicken breasts that were open and exposed to air. The freezer also had opened ice cream cup containers and food container debris lying on the floor under the shelves. Observations on [DATE], in the dry storage room revealed food crumbs and debris on the floor and the floor was sticky. Observations in the kitchen on [DATE], at 10:05 a.m. revealed that a fan with a large accumulation of dust blowing on to the food prep area, and there was food, dirt, and debris on the floor in the freezer and on the floor in the dry storage room. Interview with the Food Service Director on [DATE], 10:09 a.m. confirmed that the ice cream mix and frozen chicken breasts should have been discarded, and that the freezer and dry storage rooms should have been clean. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that facility failed to determine if a resident was safe to self-administer medications for one of 31 residents reviewed (Resident 99). Findings include: The facility's medication policy, dated January 10, 2024, indicated that self-administration was permitted when specifically authorized by the physician. Control and supervision are the responsibility of the faculty. Review of the clinical record for Resident 99 revealed that she was admitted to the facility on [DATE], and had diagnoses that included diabetes. Physician's orders for Resident 99, dated September 11, 2024, included an order that the resident could use her insulin pump (a wearable medical device that supplies a continuous flow of insulin underneath the skin) as set by her endocrinologist (doctor who specializes in the diagnosis and treatment of hormone-related diseases and conditions, including diabetes) with 100 unit per milliliter of basal Novolog (insulin used to keep your blood glucose levels stable during periods of fasting) at a rate of 0.55 units per hour. Physician's orders for Resident 99, dated September 12, 2024, included an order that the resident could manage her insulin bolus (dose of insulin taken to handle a rise in blood glucose) as set up in her insulin pump by her endocrinologist, before meals and at bedtime, making sure she notifies staff prior to self-administering each bolus. There was no documented evidence in Resident 99's clinical record to indicate that an assessment was completed to determine if she was safe to self-administer her medication. A nurse's note for Resident 99, dated September 13, 2024, at 4:10 a.m. revealed that the resident appeared to be anxious and confused at times and that she continued to manage her diabetes with a continuous glucose machine. Observations of Resident 99 on September 17, 2024, at 2:30 p.m. revealed that the resident had an insulin pump attached to her right abdomen, which she reported at the time of the observation to be functioning properly. Interview with the Director of Nursing on September 18, 2024, at 2:39 p.m. confirmed that an assessment to determine if Resident 99 was safe to self-administer her medications was not completed. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and legal guardian in writing regarding the reason for hospitalization for two of 31 residents reviewed (Residents 54, 83). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated July 25, 2024, revealed that the resident was understood, could understand others, and had a diagnosis that included a cerebral vascular accident (CVA - commonly known as a stroke) with hemiplegia (paralysis on one side of the body). Nursing notes for Resident 54, dated July 11, 2024, revealed that the resident's foley catheter (a thin, flexible tube that drains urine from the bladder into a collection bag) was changed the previous night. A urine was obtained that morning, and the resident has not had any output since. The nurse removed water from the foley catheter balloon to change it thinking that it was blocked, but blood came out from around the resident's penis and the catheter would not come out. When the nurse tried to advance the foley, blood came out. The resident had a temperature the previous night that went down but went back up to 101.2 degrees Fahrenheit (F), and he was having dyspnea (shortness of breath). The resident was started on oxygen and was sent to the emergency room and admitted with a diagnosis of sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, damaging the body's own tissues and organs). There was no documented evidence that a written notice of Resident 54's transfer to the hospital was provided to the resident and/or the resident's responsible party regarding the reason for transfer. Interview with the Business Office Manager on September 18, 2024, at 1:03 p.m. confirmed that there was no documented evidence that a written notice of Resident 54's transfer to the hospital was provided to the resident and/or the resident's responsible party regarding the reason for transfer. A quarterly MDS assessment for Resident 83, dated August 1, 2024, indicated that the resident was cognitively impaired, was dependent on staff for his daily care needs, and had diagnoses that included dementia. A nurse's note for Resident 83, dated June 2, 2024, at 2:04 p.m., revealed that the resident had decreased urine output, his abdomen was distended, and he had abnormal drainage from his penis. The physician was notified, and orders were received to transport the resident to the emergency room for evaluation. A nurse's note at 8:14 p.m. revealed that the resident was admitted to the hospital. A nurse's note for Resident 83, dated July 19, 2024, at 11:33 a.m., revealed that the physician reviewed the results of the resident's x-ray and recommended further testing be done at the hospital. The physician ordered the resident be transferred to the emergency room for evaluation. A nurse's note at 8:45 p.m. revealed that the resident was admitted to the hospital for further testing and treatment. A nurse's note for Resident 83, dated August 8, 2024, at 3:00 a.m., revealed that the resident had a change in condition that included a fever and elevated heart rate and blood pressure. The family was notified and gave permission to transfer the resident to the emergency room for evaluation. A nurse's note at 6:06 a.m. revealed that the resident was admitted to hospital. There was no documented evidence that a written notice of Resident 83's transfers to the hospital was provided to the resident's responsible party regarding the reason for transfer. Interview with the Business Office Manager on August 18, 2024, at 1:05 p.m. confirmed that the facility was not providing written notices to the residents or their responsible parties that indicated the reason for transfer to the hospital when a resident was transferred to the hospital. 28 Pa. Code 201.25 Discharge Policy. 28 Pa. Code 201.29(f)(g) Resident Rights.

Based on review of policies, as well as interviews with residents and staff, it was determined that the facility failed to ensure that residents and/or their representatives could file a grievance/concern anonymously by failing to ensure that information on how to file a grievance or complaint was available to residents or their representatives without asking. Findings include: The facility's Grievance Process policy, dated January 10, 2024, indicated that anyone may file a grievance anonymously if they chose to do so. During an interview with a group of residents on September 17, 2024, at 10:34 a.m., the residents indicated that they did not know how to file a grievance anonymously. Interview with the Director of Nursing on September 19, 2024, at 9:48 a.m. revealed that the facility's grievance forms were located behind each nursing station, and confirmed that nurses could give the forms to the residents; however, residents or their representatives could not access or file the grievance forms on their own. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(i) Resident Rights.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to issue a bed-hold notice at the time of an anticipated leave of absence from the facility for two of 31 residents reviewed (Resident 54, 83). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated July 25, 2024, revealed that the resident was understood, could understand others, and had a diagnosis that included a cerebral vascular accident (CVA - commonly known as a stroke) with hemiplegia (paralysis on one side of the body). Nursing notes for Resident 54, dated July 11, 2024, revealed that the resident's foley catheter (a thin, flexible tube that drains urine from the bladder into a collection bag) was changed the previous night. A urine was obtained that morning, and the resident has not had any output since. The nurse removed water from the foley catheter balloon to change it thinking that it was blocked, but blood came out from around the resident's penis and the catheter would not come out. When the nurse tried to advance the foley, blood came out. The resident had a temperature the previous night that went down but went back up to 101.2 degrees Fahrenheit (F), and he was having dyspnea (shortness of breath). The resident was started on oxygen and was sent to the emergency room and admitted with a diagnosis of sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, damaging the body's own tissues and organs). There was no documented evidence that a bed-hold notice was issued to Resident 54 or his responsible party at the time of his transfer to the hospital. Interview with the Business Office Manager on September 18, 2024, at 1:03 p.m. confirmed that there was no documented evidence that a bed-hold notice was issued to Resident 54 or his responsible party at the time of his transfer to the hospital. A quarterly MDS assessment for Resident 83, dated August 1, 2024, indicated that the resident was cognitively impaired, was dependent on staff for his daily care needs, and had diagnoses that included dementia. A nurse's note for Resident 83, dated June 2, 2024, at 2:04 p.m., revealed that the resident had decreased urine output, his abdomen was distended, and he had abnormal drainage from his penis. The physician was notified, and orders were received to transport the resident to the emergency room for evaluation. A nurse's note at 8:14 p.m. revealed that the resident was admitted to the hospital. A nurse's note for Resident 83, dated July 19, 2024, at 11:33 a.m., revealed that the physician reviewed the results of the resident's x-ray and recommended further testing be done at the hospital. The physician ordered the resident to be transferred to the emergency room for evaluation. A nurse's note at 8:45 p.m. revealed that the resident was admitted to the hospital for further testing and treatment. A nurse's note for Resident 83, dated August 8, 2024, at 3:00 a.m., revealed that resident had a change in condition that included a fever and elevated heart rate and blood pressure. The family was notified and gave permission to transfer the resident to the emergency room for evaluation. A nurse's note at 6:06 a.m. revealed that the resident was admitted to hospital. There was no documented evidence that a bed-hold notice was issued to Resident 83 or his responsible party at the time of his transfers to the hospital. Interview with the Business Office Manager on August 18, 2024, at 1:05 p.m. confirmed that the facility was not providing written bed-hold notices to the residents or their responsible parties when a resident was transferred to the hospital. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(3) Management.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop care plans to address individualized resident care needs for one of 31 residents reviewed (Resident 99). Findings include: The facility's policy regarding care plans, dated January 10, 2024, indicated that a resident care plan will be established within 24 hours of admission and will be reviewed and revised as indicated on readmission, significant change, and as needed for new or revised interventions. Resident care management is designed to ensure systemic comprehensive approach to assessing, planning, and meeting the resident's needs. Review of the clinical record for Resident 99 revealed that she was admitted to the facility on [DATE], and had diagnoses that included diabetes. Physician's orders for Resident 99, dated September 11, 2024, included an order that the resident may use her insulin pump (a wearable medical device that supplies a continuous flow of insulin underneath the skin) as set by her endocrinologist (doctor who specializes in the diagnosis and treatment of hormone-related diseases and conditions, including diabetes) with 100 unit per milliliter of basal Novolog (insulin used to keep blood glucose levels stable during periods of fasting) at a rate of 0.55 units per hour. Physician's orders for Resident 99, dated September 12, 2024, included an order that the resident may manage her insulin bolus (dose of insulin taken to handle a rise in blood glucose) as set up in her insulin pump by her endocrinologist, before meals and at bedtime, making sure she notifies staff prior to self-administering each bolus. Observations of Resident 99 on September 17, 2024, at 2:30 p.m. revealed that the resident had an insulin pump attached to her right abdomen, which she reported at the time of the observation to be functioning properly. As of August 16, 2024, there was no documented evidence that a care plan was developed to address Resident 99's individualized care needs related to her diabetes and self-administration of insulin using an insulin pump. Interview with the Director of Nursing on September 18, 2024, at 2:39 p.m. confirmed that Resident 99 did not have a care plan in place to address the care and treatment required for her diagnosis of diabetes and self-administering insulin using an insulin pump. 28 Pa. Code 211.10(d) Resident Care Plans.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of 31 residents reviewed (Resident 41). Findings include: The facility's policy regarding care plans, dated January 10, 2024, indicated that a resident care plan will be established within 24 hours of admission and will be reviewed and revised as indicated on readmission, significant change, and as needed for new or revised interventions. Resident care management is designed to ensure systemic comprehensive approach to assessing, planning, and meeting the resident's needs. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 41, dated August 16, 2024, indicated that the resident was understood and could usually understand others, required assistance from staff for daily care needs, and had diagnoses that included dementia and Post Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event). A psychiatry consult note for Resident 41, dated June 16, 2024, revealed that the resident acknowledged experiencing PTSD symptoms as a result of his military service. A review of Resident 41's plan of care revealed no documented evidence that his care plan was revised to address any triggers (stimulus that causes a painful memory to resurface) related to PTSD that could re-traumatize the resident. Interview with the Director of Nursing on August 19, 2024, at 8:45 a.m. confirmed that the facility did not attempt to identify Resident 41's PTSD triggers and revise his care plan to include care related to possible PTSD triggers. 28 Pa. Code 201.24(e)(4) Admission Policy. 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 residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for one of 31 residents reviewed (Resident 41). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 41, dated August 16, 2024, indicated that the resident was understood and could usually understand others, required assistance from staff for daily care needs, and had diagnoses that included dementia and PTSD. Review of the care plan for Resident 41, dated January 22, 2024, indicated that the resident had a diagnosis of dementia and PTSD. There was no documented evidence the facility identified Resident 41's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring. Interview with the Director of Nursing on August 19, 2024, at 8:45 a.m. confirmed that the facility did not complete a trauma informed care assessment on Resident 41. 28 Pa Code 201.24(e)(4) Admission Policy. 28 Pa Code 211.12(a)(d)(3)(5) Nursing Services. 28 Pa. Code 211.16(a) Social Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled for one of 31 residents reviewed (Resident 36). Findings include: The facility's policy regarding medication, dated January 10, 2024, indicated that medications that a resident brings with him/her on admission to the facility from home or another facility will be used if they are properly labeled and ordered by the physician, and the dose is the ordered dose. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated July 17, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included multiple sclerosis (MS - a chronic autoimmune disease that affects the central nervous system). Physician's orders for Resident 36, January 27, 2024, included orders for the resident to self-administer approximately sixty-one different over-the-counter biological and herbal supplements. Observations of the [NAME] Hall medication refrigerator on September 19, 2024, at 11:07 a.m. revealed that on the bottom shelf of the door were eight plastic, sandwich-size, zip-lock baggies that were 1/4 full of multiple tablets and capsules. However, there was no labeling on the eight plastic sandwich-size, zip-lock baggies to indicate who they belonged to or what the contents were. Interview with Licensed Practical Nurse 1 at the time of observation revealed that the eight plastic, sandwich-size, zip-lock baggies containing the multiple tablets and capsules belonged to Resident 36 and were her biological and herbal supplements. She indicated that the resident's son prepares the supplements at home and then brings the zip-lock baggies into the facility. She confirmed that there was no name or labeling of what the contents of the zip-lock bags contained. Interview with the Director of Nursing on September 19, 2024, at 11:55 a.m. confirmed that not having Resident 36's name on the zip lock baggies is a problem. She indicated that she maintains a list of the supplements that Resident 36 uses for the nursing staff that work on that unit. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(3) Nursing Services.

Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 31 residents reviewed (Resident 99). Findings include: Review of the clinical record for Resident 99 revealed that she was admitted to the facility on [DATE], and had diagnoses that included diabetes. Physician's orders for Resident 99, dated September 12, 2024, included an order that the resident may manage her insulin bolus (dose of insulin taken to handle a rise in blood glucose) as set up in her insulin pump (a wearable medical device that supplies a continuous flow of insulin underneath the skin) by her endocrinologist (doctor who specializes in the diagnosis and treatment of hormone-related diseases and conditions, including diabetes), before meals and at bedtime, making sure she notifies staff prior to self-administering each bolus. A nurse's note for Resident 99, dated September 15, 2024, at 10:05 a.m., revealed that the resident was nauseous and vomited. The nurse asked the resident if she gave herself a bolus of insulin, and she reported that she gave herself a small dose of less than three units. Review of the Medication Administration Record (MAR) for Resident 99, dated September 2024, revealed no documented evidence of the amount of insulin the resident was self-administering with boluses using her insulin pump. Interview with the Nursing Home Administrator on September 18, 2024, at 2:39 p.m. confirmed that there was no documented evidence of the amount of insulin the resident was self-administering with boluses using her insulin pump. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for two of 31 residents reviewed (Residents 25, 37). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. The facility's policy regarding EBP, dated January 10, 2024, indicated that the facility will prevent the spread of novel or targeted multidrug-resistant organisms (MDROs). The precautions refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands. Enhanced barrier precautions apply to all residents with wounds and or indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheostomy, or ventilator) regardless of MDRO colonization status. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated July 16, 2024, revealed that the resident was cognitively intact, required supervision with personal hygiene, had an indwelling urinary catheter (a flexible tube inserted into the bladder to collect urine into a drainage bag), and had diagnoses that included chronic kidney disease. Physician's orders for Resident 25, dated August 15, 2024, included an order for the resident to have a size 16 French Coude (type of catheter with a curved tip used to empty urine from the bladder) catheter inserted. Observations of Resident 25 on September 16, 2024, at 7:30 p.m. revealed that the resident was sitting in a recliner in his room with a catheter drainage bag in a basin on the floor to the left side of his feet. There was no signage or notification of the resident being on EBP posted at the resident's room, and there was no PPE observed in or around the resident's room. Interview with Registered Nurse 2 on September 16, 2024, at 7:56 p.m. confirmed that Resident 25 did not have EBP in place and that the resident should have. An admission MDS assessment for Resident 37, dated June 13, 2024, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, and had an indwelling urinary catheter (a soft, flexible plastic tube inserted in the bladder). Physician's orders for Resident 37, dated June 6, 2024, included an order for an indwelling foley catheter, size 14 French with a 10 milliliter balloon. Observations during the facility tour on September 16, 2024, at 7:55 p.m. revealed that Resident 37 was lying in bed with the indwelling catheter attached to the bed frame and visible from the doorway. There was no signage or notification of the resident being on EBP posted at the resident's room, and there was no PPE observed in or around the resident's room. Interview with the Director of Nursing on September 16, 2024, at 8:50 p.m. confirmed that Resident's 25 and 37 did not have EBP precautions in place and they should have. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records and investigative reports, as well as staff interviews, it was determined that the facility failed to ensure that staff implemented care-planned interventions for one of four residents reviewed (Resident 1) that was identified as a fall risk, resulting in a fall and fracture for the resident. This deficiency was cited as past noncompliance. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated January 5, 2024, revealed that the resident was cognitively intact and had diagnoses of seizure disorder. The resident's care plan, dated June 10, 2023, revealed that the resident was at risk for injury due to falls related to decreased mobility, muscle weakness, gait abnormality, lack of coordination, and history of falls. Staff was not to leave the resident alone with toileting, to walk the resident with use of gait belt (used to help nursing staff support a person who is unsteady or weak), and the resident was to be an assist two for the B (evening) and C (night) shifts. A Kardex report (a nursing worksheet that includes a summary of resident information, such as prescribed medications, clinical follow-ups, and daily care schedules) for Resident 1, dated March 7, 2024, revealed the following safety measures for staff to follow: Not to leave the resident alone with toileting, walk the resident with use of gait belt, and the resident was to be an assist two for the B (evening) and C (night) shifts. A nursing note for Resident 1, dated March 7, 2024, revealed that at 12:10 a.m. the writer was called to the resident's room. The resident was lying on the floor in the bathroom. The resident had a large amount of blood coming out of her nose. The resident stated that she was dizzy and seeing double. When the writer asked the resident what she was doing, the resident stated she was dizzy and seeing double. A nursing note for Resident 1, dated March 7, 2024, revealed that the resident returned to the facility at 6:48 p.m. from the hospital after having a fall. She was diagnosed with a closed fracture of the nasal bone and urinary tract infection (UTI). Investigative documents for Resident 1, dated March 7, 2024, revealed that the resident's assigned caregiver was Nurse Aide 1, and that the incident location occurred in the resident's bathroom. The resident stated that she got dizzy. A statement completed by Nurse Aide 1, dated March 7, 2024, revealed that he walked Resident 1 to the bathroom to get ready for bed and left her alone on the toilet while he went to help the registered nurse change a resident in another room. When finished with the other resident, he went back to Resident 1 and saw that she had fallen in the bathroom and he went to get the nurse. A interview with Nurse Aide 1, completed by the Assistant Director of Nursing for clarification on his written statement, revealed that he did not use a gait belt when walking the resident and that he transferred the resident by himself. A statement completed by the Director of Nursing, dated March 7, 2024, revealed that a call was placed to Nurse Aide 1 regarding the incident that occurred on the prior evening. Following the investigation of the fall incident and care that was delivered to the resident by this nurse aide, it was determined that neglect was identified and admitted in the employee's statement. He admitted to ambulating Resident 1 to the bathroom with an assist of only one and without using a gait belt. The resident was to be an assist of two for all ambulation and transfers during his shift and a gait belt was to be utilized. He also admitted to leaving her on the toilet in the bathroom when the resident's care plan specifically stated that she was not to be unattended in the bathroom. Failure to follow the care plan resulted in the resident falling off the toilet and sustaining a fracture, which constituted serious harm to the resident. Neglect to follow the resident's care plan that leads to serious injury of a resident is considered abuse by definition. The Director of Nursing explained this to Nurse Aide 1 on the telephone and he verbalized understanding of the reason for termination of employment. Interview with the Assistant Director of Nursing on March 14, 2024, at 11:40 a.m. confirmed that Nurse Aide 1 did not follow Resident 1's care plan of using a gait belt when walking the resident, assisting the resident with two staff when transferring, staying with the resident while she was in the restroom, and that the resident received a fracture. Follow the investigation on March 7, 2024, the facility's corrective actions included: Nurse Aide 1 was terminated from employment at the facility. Staff education on following the resident's care plan was completed. Audits to identify any issues with following a resident's care plan were started. The results of these audits will be brought to Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F656 on March 8, 2024. 28 Pa. Code 201.24(e)(4) Admission Policy. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of the facility's policies, investigation documents, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to maintain a safe environment for one of four residents reviewed (Resident 1) resulting in a fall with fracture. This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding gait belts (used to help nursing staff support a person who is unsteady or weak) for transfers and ambulation (walking), dated January 10, 2024, revealed that gait belts are provided to assist staff to safely transfer or ambulate residents. Gait belts are to be used on all residents who require one or two assist with weight bearing support for transfers and ambulation. The facility's policy regarding transfers, dated January 10, 2024, revealed that the facility must ensure that each resident receives adequate supervision and assistance. Staff will use a gait belt for all one or two assist transfers unless the lift is utilized. An assessment card will be posted above the resident's bed. The dot system will be utilized above the resident's bed to help communicate the resident's needs for assistance to direct care staff. The amount of assistance required by the resident will also be placed in the resident's care plan and flow sheets. The assessment card and the care plan indicates the least amount of assistance that the resident requires and they can be provided with more assistance depending on the abilities of the resident on a particular day and/or staff. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated January 5, 2024, revealed that the resident was cognitively intact and had a diagnosis of seizure disorder. The resident's care plan, dated June 10, 2023, revealed that the resident was at risk for injury due to falls related to decreased mobility, muscle weakness, gait abnormality, lack of coordination, and a history of falls. Staff was to walk the resident with the use of a gait belt, not leave the resident alone with toileting, and the resident was an assist two for the B (evening) and C (night) shifts. A Kardex report (a nursing worksheet that includes a summary of patient information, such as prescribed medications, clinical follow-ups, and daily care schedules) for Resident 1, dated March 7, 2024, revealed the following safety measures for staff to follow: Not to leave the resident alone with toileting, walk the resident with the use of a gait belt, and the resident was to be an assist two for the B (evening) and C (night) shifts. A nursing note for Resident 1, dated March 7, 2024, revealed that at 12:10 a.m. the writer was called to the resident's room. The resident was lying on the floor in the bathroom. The resident had a large amount of blood coming out of her nose. The resident stated that she was dizzy and seeing double. When I asked the resident what she was doing, the resident stated she was dizzy and seeing double. A nursing note for Resident 1, dated March 7, 2024, revealed that the resident returned to the facility at 6:48 p.m. from the hospital after having a fall. She was diagnosed with a closed fracture of the nasal bone and urinary tract infection (UTI). Investigative documents for Resident 1, dated March 7, 2024, revealed that the resident's assigned caregiver was Nurse Aide 1 and that the incident location occurred in the resident's bathroom. The resident stated that she got dizzy. A statement completed by Nurse Aide 1, dated March 7, 2024, revealed that he walked Resident 1 to the bathroom to get ready for bed and left her on the toilet alone while he went to help the registered nurse change a resident in another room. When finished with the other resident, he went back to Resident 1 and saw that she had fallen in the bathroom and went to get the nurse. A interview with Nurse Aide 1, completed by the Assistant Director of Nursing for clarification on his written statement, revealed that he did not use a gait belt when walking the resident and that he transferred the resident by himself. A statement completed by the Director of Nursing, dated March 7, 2024, revealed that a call was placed to Nurse Aide 1 regarding the incident that occurred on the prior evening. Following the investigation of the incident involving a fall and care that was delivered to the resident by this nurse aide, it was determined that neglect was identified and admitted in the employee's statement. He admitted to not using a gait belt to ambulate the resident to the bathroom with one assist. The resident was to be an assist of two for all ambulation and transfers during his shift and a gait belt was to be utilized. He also admitted to leaving her on the toilet in the bathroom when the resident's care plan specifically stated that she was not to be unattended in the bathroom. Failure to follow the care plan resulted in the resident falling off the toilet and sustaining a facial fracture, which constituted serious harm to the resident. Neglect to follow the resident's care plan that leads to serious injury of a resident is considered abuse by definition. The Director of Nursing explained this to Nurse Aide 1 on the telephone and he verbalized understanding of the reason for termination of employment. Interview with the Assistant Director of Nursing on March 14, 2024, at 11:40 a.m. confirmed that Nurse Aide 1 did not follow Resident 1's care plan of using a gait belt when walking the resident, assisting the resident with two staff when transferring, staying with the resident while she was in the restroom, and that the resident received a fracture. Follow the investigation on March 7, 2024, the facility's corrective actions included: Nurse Aide 1 was terminated from employment at the facility. Staff education on following the resident's care plan for assistance with ambulation/transfers was completed. Audits to identify any issues with following a resident's care plan for assistance with ambulation/transfers were started. The results of these audits will be brought to Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F689 on March 8, 2024. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies, investigative reports, and residents' clinical records, as well as staff family interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's care plan for preventing falls for one of four residents reviewed (Resident 1), resulting in a fall and fracture for the resident. This deficiency was cited as past noncompliance. Findings include: The facility's policy regarding resident abuse, dated January 10, 2024, revealed that neglect is defined as the failure of the facility, its employees, or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated January 5, 2024, revealed that the resident was cognitively intact and had diagnoses of seizure disorder. The resident's care plan, dated June 10, 2023, revealed that the resident was at risk for injury due to falls related to decreased mobility, muscle weakness, gait abnormality, lack of coordination, and history of falls. Staff was not to leave the resident alone with toileting, to walk the resident with use of gait belt (used to help nursing staff support a person who is unsteady or weak), and the resident was to be an assist two for the B (evening) and C (night) shifts. A Kardex report (a nursing worksheet that includes a summary of patient information, such as prescribed medications, clinical follow-ups, and daily care schedules) for Resident 1, dated March 7, 2024, revealed the following safety measures for staff to follow: Not to leave the resident alone with toileting, to walk the resident with use of gait belt, and the resident was to be an assist two for the B (evening) and C (night) shifts. A nursing note for Resident 1, dated March 7, 2024, revealed that at 12:10 a.m. the writer was called to the resident's room. The resident was lying on the floor in the bathroom. The resident had a large amount of blood coming out of her nose. The resident stated that she was dizzy and seeing double. When the writer asked the resident what she was doing, the resident stated she is dizzy and seeing double. A nursing note for Resident 1, dated March 7, 2024, revealed that the resident returned to the facility at 6:48 p.m. from the hospital after having a fall. She was diagnosed with a closed fracture of the nasal bone and a urinary tract infection (UTI). Investigative documents for Resident 1, dated March 7, 2024, revealed that the resident's assigned caregiver was Nurse Aide 1, and that the incident occurred in the resident's bathroom. The resident stated that she got dizzy. A statement completed by Nurse Aide 1, dated March 7, 2024, revealed that he walked Resident 1 to the bathroom to get ready for bed, then left her alone on the toilet while he went to help the registered nurse change another resident in another room. When finished with the other resident, Nurse Aide 1 went back to Resident 1 and saw that she had fallen in the bathroom. He then went to get the nurse. A statement completed by the Director of Nursing, dated March 7, 2024, revealed that a call was placed to Nurse Aide 1 regarding the incident that occurred on the prior evening. Following the investigation of the incident, fall, and care delivered to the resident by this nurse aide, it was determined that neglect was identified and admitted in the employee's statement. He admitted to ambulating the resident to the bathroom with one assist and not using a gait belt. The resident was to be an assist of two for all ambulation and transfers during his shift and a gait belt was to be utilized. He also admitted to leaving her on the toilet in the bathroom when the resident's care plan specifically stated that she was not to be unattended in the bathroom. Failure to follow the care plan resulted in the resident falling off the toilet and sustaining multiple facial fractures and constituted serious harm to the resident. Neglect to follow the resident's care plan that leads to serious injury of a resident is considered abuse by definition. The Directed of Nursing explained this to Nurse Aide 1 on the telephone and he verbalized understanding of the reason for termination of employment. Review of Nurse Aide 1's personnel file revealed that he was hired by the facility as a nurse aide on October 12, 2011, and that he had completed training regarding preventing, recognizing, and reporting abuse on April 7, 2023. Interview with the Assistant Director of Nursing on March 14, 2024, at 11:40 a.m. confirmed that the facility's investigation substantiated neglect because Nurse Aide 1 did not follow Resident 1's care plan, did not use a gait belt when walking the resident, did not assist the resident with two staff when transferring, did not stay with the resident while she was in the restroom, and the resident received a fracture. Following the investigation on March 7, 2024, the facility's corrective actions included: Nurse Aide 1 was terminated from employment at the facility. Staff education on abuse was completed. Audits to identify any issues with abuse were started. The results of these audits will be brought to Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F600 on March 8, 2024. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies, investigative reports, and residents' clinical records, as well as staff and family interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's care plan and the facility's policy for preventing falls for one of five residents reviewed (Resident 1), resulting in a fracture for the resident. Findings include: The facility's policy regarding fall prevention and protocol, dated December 14, 2021, indicated that staff members will be written up as a negative performance notation for failing to use the recommended interventions or failing to put a resident alarm in the on position. Failure to turn an alarm on which results in resident injury may be considered and written up as neglect of care under the regulations for resident abuse. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 18, 2022, revealed that the resident was cognitively impaired, was dependent on staff for transfers, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan, dated February 18, 2022, included that she have a wall alarm (senses resident getting out of bed and alarms) on when in bed. A nursing note for Resident 1, dated June 26, 2022, revealed that the nurse was called to the resident's room when she fell to the floor. The bedside alarm had not sounded because it was not turned on. A nursing note for Resident 1, dated June 26, 2022, revealed that the physician was made aware of the resident's fall and complaints of pain in the leg and that he ordered x-rays. The x-ray revealed that the resident suffered a fracture of the left proximal fibula (left lower leg bone). Investigative documents for Resident 1, dated June 26, 2022, revealed that on June 26, 2022, Nurse Aide 1 provided care to Resident 1's roommate many times through the night of June 26. She stated that she turned the alarm off in order to provide care for the roommate without the alarm sounding and that she failed to turn Resident 1's wall alarm (motion sensor alarm) back on when leaving the room. The facility's investigation determined that Nurse Aide 1 had received annual training for neglect and personal alarms for residents, and that she violated the facility's policy when she failed to turn the alarm on prior to leaving the room. Interview with Resident 1's daughter on July 12, 2022 at 11:49 a.m. revealed that she had feared that her mother would fall out of bed and get hurt because her mother is impulsive. She further stated that the facility told her that a nurse aide failed to turn the alarm on prior to leaving the room and therefore the alarm did not sound when her mother was getting out of bed. Interview with the Assistant Director of Nursing on July 12, 2022, at 3:49 p.m. confirmed that Nurse Aide 1 failed to turn Resident 1's wall alarm on per her care plan and the resident fell when attempting to get out of bed and received a fracture. 42 CFR 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of policies, clinical records, and information provided by the facility, as well as staff interviews, it was determined that the facility failed to ensure that care plans for accident prevention were followed, resulting in a fractured arm for one of four residents reviewed (Resident 1), and failed to ensure that a thorough investigation was completed and new interventions attempted following a fall for one of four residents reviewed (Resident 4). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated (MONTH) 13, 2019, indicated that the resident was cognitively impaired and required supervision for ambulation (walking). A nursing note, dated (MONTH) 20, 2019, indicated that the resident was returning from the bathroom and fell to the floor onto her buttocks, and a note on (MONTH) 21, 2019, indicated that she had increased back pain from the recent fall, that she had mild [MEDICAL CONDITION] (degeneration of joint cartilage and the underlying bone) and that an x-ray was negative for fracture. A therapy assessment for Resident 1, dated (MONTH) 26, 2019, indicated that she required the assistance of one person for transfers, ambulation, and toileting due to decreased range of motion (joint mobility), strength, and a high pain level due to her recent fall. Therapy also recommended a bed alarm. A safety risk assessment and the resident's care plan, dated (MONTH) 26, 2019, indicated that she had an unsteady gait and required an assistive device for ambulation. A new intervention added to her fall prevention care plan was to have a ceiling alarm (mounted on the ceiling and sounds an alarm when it picks up motion near the bed) on at all times while the resident was in her room, and that she now needed the assistance of one person for all transfers and ambulation. A nursing note for Resident 1, dated (MONTH) 1, 2019, at 4:45 a.m. revealed that the resident was found on the floor with her back against the wall by the bathroom door. The resident complained of wrist pain and had a hematoma above the right eyebrow that measured 3.0 x 1.5 centimeter (cm). At the time of the fall, it was noted that the resident's ceiling alarm was in the off position. Information provided by the facility, dated (MONTH) 1, 2019, indicated that Nurse Aide 1 went into Resident 1's room to offer toileting at 2:57 a.m. and that when leaving the room, Nurse Aide 1 did not turn the ceiling alarm back on. A nursing note for Resident 1, dated (MONTH) 1, 2019, at 9:20 a.m. indicated that the resident complained of pain, had right wrist bruising and swelling, and that she was unable to use it. An x-ray of the right wrist, dated (MONTH) 1, 2019, indicated that she had a mildly impacted fracture of her distal radius (a lower arm bone), and a nursing note dated (MONTH) 2, 2019, indicated that the resident had a cast applied on her right forearm. Interview with the Assistant Director of Nursing on (MONTH) 6, 2019, at 3:30 p.m. confirmed that Nurse Aide 1 did not follow Resident 1's care plan and turn the ceiling alarm on when the resident was in the room. A quarterly MDS assessment for Resident 4, dated (MONTH) 27, 2019, indicated that the resident was cognitively intact, was independent for transfers and mobility, used a walker, had a history of [REDACTED]. Incident reports (2019) for Resident 4 dated (MONTH) 6 at 4:30 p.m., (MONTH) 12 at 3:15 p.m., (MONTH) 13 at 12:30 a.m., (MONTH) 18 at 2:40 a.m., (MONTH) 22 at 3:05 p.m., (MONTH) 2 at 1:15 p.m., (MONTH) 3 at 5:45 a.m., (MONTH) 3 at 7:00 a.m., (MONTH) 4 at 12:55 a.m. and (MONTH) 4 at 6:15 p.m., revealed that Resident 4 had unwitnessed falls in her room from her recliner and from her bed. There was no documented evidence that any new interventions were initiated after Resident 4's fall on (MONTH) 18, and (MONTH) 2, 3 and 4, 2019. The incident reports for Resident 4 dated (MONTH) 12 and (MONTH) 22, 2019, indicated that the resident's walker was not within her reach, the reports for (MONTH) 13, (MONTH) 18 and (MONTH) 4, 2019, did not indicate if the resident's walker was within her reach or in use at time of the falls, and there was no documented evidence that thorough investigations were completed regarding why the walker was not within her reach or in use at the time of the falls, and including if all interventions were in place at the time of the falls. Interviews with the Director of Nursing and Assistant Director of Nursing on (MONTH) 6, 2019, at 4:30 p.m. confirmed that Resident 4 had frequent falls, that new interventions were not always initiated following the falls, and that the facility's investigations did not indicate why Resident 4's walker was not within reach or not in use at the time of the falls. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 5/3/18, 3/15/18, 1/8/18, 11/9/17. 28 Pa. Code 201.18(e)(1) Management. Previously cited 9/28/18, 5/3/18, 11/9/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 12/20/18, 9/28/18, 5/3/18, 3/15/18, 1/8/18, 11/9/17.

Based on review of manufacturer's directions, clinical records, incident/accident reports, and information submitted by the facility, as well as staff interviews, it was determined that the facility failed to ensure that safe techniques were used during mechanical lift transfers for one of eleven residents reviewed (Resident 2), resulting in a fall with an arm and leg injury. Findings include: Manufacturer's directions for use for the Invacare Reliant 450 and Reliant 600 electric portable patient lifts (a device that uses hydraulic power to lift and transfer residents from surface to surface), dated (MONTH) 2011, revealed that the definition of a WARNING was a potentially hazardous situation, which if not avoided, could result in death or serious injury. The directions included an ACCESSORIES WARNING, which stated that Invacare products were specifically designed and manufactured for use in conjunction with Invacare accessories, and accessories designed by other manufacturers have not been tested by Invacare and are not recommended for use with Invacare products. The operating information for the lifts included a WARNING which stated that Invacare slings and patient lift accessories were specifically designed to be used in conjunction with Invacare patient lifts, and slings and accessories designed by other manufacturers were not to be utilized as a component of Invacare's patient lift system. The sling information for the lifts included a WARNING which stated to use an Invacare approved sling that was recommended by the individual's doctor, nurse or medical assistant for the comfort and safety of the individual being lifted. A safety inspection checklist indicated that all sling attachments were to be checked each time it was used to ensure proper connection and patient safety. For patient safety, the sling material and straps were to be checked initially and monthly for wear. Manufacturer's direction for use of Invacare patient slings, dated (MONTH) 31, 2013, included that the definition of a WARNING was a potentially hazardous situation, which if not avoided, could result in death or serious injury. The directions included a WARNING which stated that Invacare slings were made specifically for use with Invacare lifts, and that for patient safety, DO NOT intermix slings and lifts of different manufacturers. The facility's policy regarding mechanical lift operation, revised (MONTH) (YEAR), indicated to always follow individual manuals for specific lift operation, that all lift slings were to be inspected for normal wear and tear with each use, and that if a lift sling was found to be weak for transfer, it was to be given to the Director of Nursing for inspection purposes. Lifts used in the facility are the Invacare Reliant 450 and Reliant 600. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated (MONTH) 27, (YEAR), revealed that the resident was understood, could understand, and required extensive assistance from staff for her daily care, including transfers. The resident's care plan, revised on (MONTH) 12, (YEAR), indicated that the resident was to be transferred using a mechanical lift. An incident note for Resident 2, dated (MONTH) 15, (YEAR), at 2:41 p.m. revealed that the resident was on the floor, after the lift sling broke during a transfer. Two staff members were in the room operating the lift and inspected the sling prior to transfer, and found it was not frayed. The resident was lying on her right side on top of the lift sling. Staff were able to move the resident to remove the mechanical lift from underneath her and while lifting her gently, blood was noted coming from the right forearm. A nurse cut the resident's right sleeve and noted bone sticking out of her skin. A nursing note for Resident 2, dated (MONTH) 15, (YEAR), at 3:16 p.m. revealed that the resident's shirt sleeve was cut up to the shoulder to assess the wound underneath, which was a large, deep laceration to the right forearm with no exposed bone. An emergency department physician's note for Resident 2, dated (MONTH) 15, (YEAR), revealed that the resident had a large laceration to the right forearm that was approximately 10 centimeters (cm), and that ten absorbable sutures were placed subcutaneously (beneath the skin) and the wound was closed with 13 sutures. A written statement from Nurse Aide 2, dated (MONTH) 15, (YEAR), revealed that at 1:35 p.m. she and Nurse Aide 3 were getting Resident 2 changed and ready to get her up to her chair. She found a leg lift cover (a criss-cross sling that crosses between the resident's legs), but she does not like using that type of sling, so she went to the laundry department to get another lift sling. She looked the lift slings over and picked lift sling six, which she felt was a good lift sling. She returned to the resident's room and she and Nurse Aide 3 placed the lift sling under the resident and began to lift her. When they started to move the resident away from the bed, the lift sling snapped and the resident dropped to the floor, landing sideways on the legs of the mechanical lift. A written statement from Nurse Aide 3, dated (MONTH) 15, (YEAR), revealed that she and Nurse Aide 2 were getting Resident 2 changed and ready to get up. There was a criss-cross lift sling in the room and Nurse Aide 2 did not like that one, so she went to laundry and brought up a different sling. She looked at the straps before hooking them to the lift and they looked fine. As soon as they moved the resident away from the bed, the lift sling snapped and the resident landed sideways on the lift legs. An incident note for Resident 2, dated (MONTH) 19, (YEAR), at 7:45 p.m. revealed that the resident's family member wanted the nurse to assess the resident's right lower leg. It was noted that the bruise from the resident's previous fall now had a raised fluid-filled blister on it that measured 2.5 x 2.5 cm. A nursing note for Resident 2, dated (MONTH) 11, (YEAR), at 4:15 p.m. revealed that while at the hospital for another reason, the resident's right leg was debrided (to remove all materials that may promote infection and impede healing). A nursing note, dated (MONTH) 14, (YEAR), at 6:23 p.m. revealed that the resident's family member was concerned that there was a pocket of fluid above the wound (to the right lower leg). The resident's family requested that the resident be seen by a plastic surgeon for wound care. A wound clinic note for Resident 2, dated (MONTH) 17, (YEAR), revealed that the resident was seen for evaluation and management of a hematoma (a pocket of blood beneath the skin). The note indicated that on (MONTH) 11, (YEAR), while the resident was in the hospital for another reason, the hematoma was debrided, leaving an open wound. An assessment revealed a full-thickness ulceration (a sore on the skin or a mucous membrane, accompanied by the disintegration of tissue) of the right leg measuring 5.0 x 2.5 x 0.5 (depth) cm. The wound edges were non-adherent to the wound base with tunneling (channels that extend from a wound into and through subcutaneous tissue or muscle) of 4.8 cm at the 12:00 position, and undermining (when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge) from the 6:00 to 10:00 positions with 2.0 cm at the 9:00 position. A plastic surgeon's progress note for Resident 2, dated (MONTH) 23, (YEAR), revealed that the resident had a wound to her right lower leg following a fall from a mechanical lift on (MONTH) 15, (YEAR). The wound measured 5.0 x 3.7 x 0.5 cm with tunneling of 5.0 cm at the 12:00 position and 1.5 cm at the 9:00 position. Information submitted by the facility on (MONTH) 19, (YEAR), revealed that the mechanical lift in use at the time of Resident 2's incident was an Invacare Reliant 450 model, and that it uses Drive and Invacare brand lift slings. The sling in use during the incident was a Drive brand lift sling and the facility was unable to determine when the lift sling was purchased. All Drive lift slings were removed from service. The most recent training on mechanical lifts for Nurse Aides 2 and 3 was completed on (MONTH) 20, (YEAR), and the Director of Nursing was re-inservicing all nurse aides with a mandatory return demonstration on the use of mechanical lifts, which was completed on (MONTH) 28, (YEAR). The information indicated that the Invacare manufacturer recommended using their own Invacare accessories, and all Drive lift slings were removed from use. An Invacare representative was to schedule inservices with staff regarding mechanical lift transfers and safe resident handling. In the future, all lift slings were to be ordered through Invacare. Documentation provided by the facility revealed that on (MONTH) 20, (YEAR), the facility started to place an identifying number on each lift sling and document the initial and monthly inspections of the lift slings. Interviews with the Director of Nursing on (MONTH) 2, (YEAR), at 10:38 a.m. and 11:19 a.m. revealed that the facility did not have a written policy regarding lift slings. She confirmed that a Drive brand sling was in use at the time of Resident 2's incident, and since the incident, the facility removed all Drive lift slings from service and started to complete monthly checks of the lift slings. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 3/15/18, 1/8/18, 11/9/17, 4/3/17, 12/23/16. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/23/16. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 11/9/17, 12/23/16. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 3/15/18, 11/9/17, 10/5/17, 12/23/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 3/15/18, 10/5/17, 5/11/17, 12/23/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 3/15/18, 1/8/18, 11/9/17, 10/5/17, 5/11/17, 4/3/17, 12/23/16.

Based on review of policies, investigative reports and clinical records, as well as staff interviews and observations, it was determined that the facility failed to take precautions to prevent injury to a resident caused by not having foot rests on her wheelchair during transport for one of 27 residents reviewed (Resident R10) resulting in a fall with a head injury, and failed to take precautions to prevent falls for two of 27 residents reviewed (Residents R15, R17). Findings include: The facility's policy regarding the use of wheelchairs, dated March 21, 2017, indicated that the procedure for transporting residents to and from places included lowering the foot rests (a supportive surface on a wheelchair for the feet to rest on) and placing the resident's feet on the foot rests, if used, and to position the feet and legs in good body alignment and elevate the feet if ordered. A comprehensive annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R10, dated September 14, 2017, revealed that the resident was confused, did not ambulate (walk), and needed extensive assistance from staff for all of her care. A [DIAGNOSES REDACTED]. situations). The resident's care plan, originally dated October 23, 2015, and most recently reviewed on September 14, 2017, revealed that the resident was at risk for falls. A physician's orders [REDACTED]. A nursing note for Resident R10, dated October 13, 2017, at 12:26 p.m. revealed that the resident was showing a decline in her active range of motion (her ability to move her joints independently) and standing. The note indicated that the resident stood three times that week, she had one day that she stood for 30 seconds, and the other days she could not even come to a full stand, and she really pushed back with each stand. She required the maximum assistance of two and refused active range of motion each time stating that she was either too tired or too sick. There was no documented evidence in Resident R10's clinical record to indicate that she was offered or refused to use foot rests while in a wheelchair. An incident report for Resident R10, dated November 1, 2017, at 5:38 p.m. revealed that Nurse Aide 1 was pushing the resident out of the dining room in her wheelchair. Nurse Aide 1 stated that the resident put her feet flat on the floor while she was pushing her, which resulted in the resident being ejected forward out of the chair and landing face first on the floor. Resident R10 had a large amount of bleeding coming from her head. Upon examination, the resident was noted to have a large horseshoe-shaped scalp laceration above her right eye with a skin flap hanging down over the eye. The resident did not have foot rests on her wheelchair. The resident was sent to the hospital by ambulance and returned to the facility with 31 sutures to her right forehead laceration. There was no documented evidence in Resident R10's clinical record to indicate that she was assessed to determine if it was safe for the resident to be transported in a wheelchair without the use of foot rests. An interview with the Director of Nursing on November 7, 2017, at 10:00 a.m. confirmed that Resident R10 should have had foot rests on her wheelchair when being transported from the dining room. A quarterly MDS for Resident R15, dated September 13, 2017, revealed that she was alert and oriented, required extensive assistance with care, and had [DIAGNOSES REDACTED]. The resident's care plan, dated August 6, 2015, revealed that she was at risk for falls. Observation of Resident R15 on November 7, 2017, at 2:30 p.m. revealed that the resident was being pushed in her wheelchair by Activity Aide 2 and there were no foot rests on the resident's wheelchair. Interview with Activity Aide 2 on November 7, 2017, at 2:30 p.m. revealed that Resident R15 refuses the use of foot rests. However, there was no documented evidence in Resident R15's clinical record to indicate that foot rests were offered and/or refused, or that the resident was assessed to determine if it was safe to transport the resident in a wheelchair without foot rests. A quarterly MDS assessment for Resident R17, dated October 25, 2017, revealed that the resident was alert and oriented, required extensive assistance for all of her care, and had [DIAGNOSES REDACTED]. The resident's care plan, dated October 25, 2017, revealed that she was at risk for falls and had decreased mobility due to weakness and arthritis. Observation of Resident R17 on November 6, 2017, at 5:11 p.m. revealed that the resident was pushed in her wheelchair by Nurse Aide 3 and there were no foot rests on the wheelchair. Interview with Nurse Aide 3 on November 6, 2017, at 5:11 p.m. confirmed that there were no foot rests on Resident R17's wheelchair, and she was not aware that there should be. There was no documented evidence in Resident R17's clinical record to indicate that she was assessed to determine if it was safe for the resident to be transported in a wheelchair without foot rests. An interview with the Director of Nursing on November 7, 2017, at 3:00 p.m. confirmed that foot rests should have been used on Residents R15's and R17's wheelchairs during transport by staff. 42 CFR 483.25(d)(1)(2) Free of Accidents Hazards/Supervision/Devices. Previously cited 4/3/17, 12/23/16. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 12/23/16. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10(a) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 10/5/17, 5/11/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/5/17, 5/11/17, 4/3/17, 12/23/16, 11/19/15.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide a safe environment that was free from potential fire hazards caused by the placement of beds against electrical wall outlets for six of 29 residents reviewed (Residents R13, R17, R18, R19, R20, R21), resulting in the residents' safety being placed in Immediate Jeopardy. The facility also failed to ensure that the residents' environment was free from potential safety hazards caused by unsupervised steam tables that were hot and accessible to residents in three of four dining areas (Doerr Dining Room, Glass Dining Room, West Dining Room). Findings include: The facility's policy and procedure manual, dated October 4, 2016, did not include procedures for the evaluation of the resident's environment for fire hazards when a resident's bed was to be placed against the wall. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R13, dated November 9, 2016, revealed that the resident was cognitively impaired and she required assistance from the staff for all of her care and mobility. The resident's care plan, last reviewed on November 9, 2016, revealed that the resident's bed was to be placed against the wall to create environmental space. Observations on December 20, 2016, at 9:20 a.m. revealed that Resident R13's bed was against the wall with the bed linens in contact with the electrical outlet. A quarterly MDS assessment for Resident R17, dated November 30, 2016, revealed that the resident was cognitively impaired and she required assistance from staff for all of her care and mobility. The resident's care plan, dated March 17, 2016, indicated that the resident had decreased mobility, was at risk for falls, and the resident's bed was to be placed against the wall to create environmental space. A Safety Assessment Tool completed for the resident on November 23, 2016, revealed that it did not contain an assessment/evaluation of the resident's environment for fire hazards. Observations on December 20, 2016, at 9:39 a.m. revealed that Resident R17's bed was against the wall with the bed linens in contact with the electrical outlet, and the bed's electrical cord was plugged into one outlet receptacle. A quarterly MDS assessment for Resident R18, dated October 12, 2016, revealed that the resident was cognitively impaired, and she required assistance for bed mobility and transfers. The resident's care plan, dated October 12, 2016, indicated that the resident was at risk for falls, and her bed was to be against the wall to create environmental space. A Safety Assessment Tool completed for the resident on October 22, 2016, revealed that it did not contain an assessment/evaluation of the resident's environment for fire hazards. Observations on December 20, 2016, at 9:43 a.m. revealed that Resident R18's bed was against the wall with the bed linens in contact with the electrical outlet, and there was a portable phone, an answering machine, and a surge protector plugged into the outlet receptacles. An annual MDS assessment for Resident R19, dated December 7, 2016, revealed that the resident was alert and oriented, and she required assistance from staff for all of her care and mobility. The resident's care plan, last reviewed on December 7, 2016, indicated that the resident had decreased mobility, was at risk for falls, and her bed was to be placed against the wall to create environmental space. A Safety Assessment Tool completed for the resident on December 1, 2016, revealed that it did not contain an assessment/evaluation of the resident's environment for fire hazards. Observations on December 20, 2016, at 9:54 a.m. revealed that Resident R19's bed was against the wall with the bed linens in contact with the electrical outlet. A quarterly MDS assessment for Resident R20, dated November 22, 2016, revealed that the resident was cognitively impaired and required limited assistance with bed mobility and transfers. The resident's care plan, dated June 26, 2016, revealed that she was at risk for falls, and her bed was to be against the wall to create environmental space. A Safety Assessment Tool completed for the resident on November 27, 2016, revealed that it did not contain an assessment/evaluation of the resident's environment for fire hazards. Observations on December 20, 2016, at 9:48 a.m. revealed that Resident R20's bed was against the wall with the bed linens in contact with the electrical outlet, and three of four receptacles were in use. A quarterly MDS assessment for Resident R21, dated November 30, 2016, revealed that the resident was cognitively impaired and required extensive assistance with bed mobility and transfers. The resident's care plan, dated November 30, 2016, indicated that the resident was at risk for falls, and the bed was to be up against the wall to create environmental space. A Safety Assessment Tool completed for the resident on November 23, 2016, revealed that it did not contain an assessment/evaluation of the resident's environment for fire hazards. Observations on December 20, 2016, at 9:48 a.m. revealed that Resident R21's bed was against the wall with the bed linens in contact with the electrical outlet. Interview with the Nursing Home Administrator (NHA) on December 20, 2016, at 11:05 a.m. revealed that he was not aware that residents' bed linens should not be in contact with electrical outlets. On December 20, 2016, at 11:00 a.m. the NHA was informed that Residents R13, R17, R18, R19, R20, and R21's safety was in Immediate Jeopardy due to fire hazards created by bed linens being in contact with electrical outlets. The facility submitted a plan to correct the Immediate Jeopardy on December 20, 2016, at 4:27 p.m. that included an evaluation of all residents' rooms to ascertain if beds were against the wall, and if they were, the beds were to be moved away from the wall and outlets. Outlet protectors were to be placed in outlets that were not currently in use. Staff from housekeeping, maintenance, nursing, and activities were to receive education regarding the hazards of residents' beds being against the wall and electrical outlets, to keep beds away from outlets, and to keep outlets covered with an outlet protector. Maintenance staff were to monitor residents' rooms daily for 30 days. Observations on December 21, 2016, at 9:15 a.m. revealed that the above residents' beds were moved away from the walls, and at 1:00 p.m. the NHA submitted information to show that 92 percent of the staff received education regarding the hazards of residents' beds being against the wall and against electrical outlets. The Immediate Jeopardy was lifted on December 21, 2016, at 1:00 p.m. The facility's policy and procedure manual, dated October 4, 2016, did not include procedures regarding the management/security of steam tables located in dining areas when the tables were not in use. Observations in the Doerr Wing Dining Room on December 19, 2016, at 7:03 p.m. revealed that the steam table located in the room was turned off, but the lids and sides of the water wells were hot to touch. The surface temperature of the second well lid was 130 degrees Fahrenheit (F). The door to the dining area was open, and there were no staff in the room. Observations in the West Wing Dining Room on December 21, 2016, at 11:00 a.m. revealed that the steam table located in the room was turned off, but the lids and sides of the water wells were hot to the touch. The water temperature of the first well was 116.2 degrees F; the surface temperature of the second well lid was 148.2 degrees F, and the water in the well was 174.7 degrees F; the surface temperature of the third well lid was 147 degrees F, and the water in the well was 172.9 degrees F; the surface temperature of the fourth well lid was 158.3 degrees F, and the water in the well was 182.4 degrees F. Three doors to the dining area were open and there were no staff in the room. Observations in the Glass Dining Room on December 21, 2016, at 11:06 a.m. revealed that the steam table located in the room was turned off, but the lids and sides of the water wells were hot to touch. The water temperature in the second well was 136.7 degrees F; the surface temperature of the third well lid was 120.7 degrees F, and the water in the well was 139.2 degrees F; the water temperature in the fourth well was 123.6 degrees F. One side door entrance from the Doerr Wing and one side door entrance from the West Wing were open, and there were no staff present. Observations in the Glass Dining Room on December 21, 2016, at 1:20 p.m. revealed that the steam table located in the room was turned off, but the lids and sides of the water wells were hot to touch. The water temperature in the first well was 130.6 degrees F; the surface temperature of second well lid was 144.8 degrees F, and the water in the well was 172.5 degrees F; the surface temperature of the third well lid was 158 degrees F, and the water in the well was 179 degrees F; the surface temperature of the fourth well lid was 150 degrees F, and the water in the well was 176.9 degrees F. One side door entrance from the Doerr Wing and one side door entrance from the West Wing were open, and there were no staff present. Observations in the Doerr Wing Dining Room on December 21, 2016, at 1:26 p.m. revealed that the steam table located in the room was turned off, but the lids and sides of the fourth and fifth water wells were hot to touch. The surface temperature of the fourth well lid was 116.2 degrees F, and the water in the well was 139.8 degrees F; the surface temperature of the fifth well lid was 117.5 degrees F, and the water in the well was 136.4 degrees F. The door to the dining area was open, and there were no staff in the room. Interview with the NHA on December 21, 2016, at 1:45 p.m. confirmed that the steam table lids in the Glass Dining Room were hot to the touch. Interview with the Food Service Director on December 21, 2016, at 2:10 p.m. confirmed that the facility does not have a policy regarding the management/security of the steam tables in the dining areas when they are not in use. He indicated that the steam tables are turned on when staff bring the food to the dining areas, and are turned off at the conclusion of the meal. He indicated that staff do not stay in the dining areas after the meals are served, and that he was not aware that the steam tables temperatures were remaining hot after being turned off. 42 CFR 483.25(d)(1)(2)(n)(1)-(3) Free of Accidents/Supervision/Devices. Previously cited 12/18/14. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 11/19/15, 3/31/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 11/19/15, 3/31/15, 12/18/14.

Based on clinical record reviews, observations, and staff interviews, as well as review of policies, it was determined that the facility failed to provide pain management for one of 25 residents reviewed (Resident R5) and failed to follow physician orders [REDACTED]. Findings include: A [DIAGNOSES REDACTED]. Physician orders, dated 8/30/13, revealed that the resident was on hospice care and that he was to receive comfort medications. A hospice nursing note, dated 10/10/13, indicated that the resident was not able to describe or rate the pain he had when asked. A nursing note, dated 11/4/13, indicated that the resident's left great toe and part of the second toe were necrotic, that his great toe to his fifth toe were necrotic on his right foot, and he had a wound on his coccyx that was getting worse. Physician orders, dated 10/28/13, revealed that the resident was to receive 5 milligrams (mg.) of Roxinol (a pain medication) as needed for pain 30 minutes before staff turned and repositioned him. Physician orders, dated 10/31/13, revealed that the resident could have the Roxinol as frequently as every two hours as needed for his pain. A nursing note, dated 11/6/13, revealed that a care plan conference was held and that the resident was to have a medication to alleviate pain when he was touched or repositioned. The resident's care plan, updated 11/6/13, revealed that due to multiple medical problems and gangrenous toes, the resident had severe pain with movement, including with turning and repositioning, and staff were to notify the medication nurse if the resident verbalized pain or if he had pain during direct care. A nursing note, dated 11/7/13, revealed that the resident cried out during care when he was moved by the staff. Review of the resident's medication administration records for November 2013 revealed no documented evidence that the resident was medicated with Roxinol as needed for pain prior to turning and repositioning as ordered by the physician. Observations during care provided to the resident on 11/12/13 at 1:55 p.m. revealed that the resident moaned when touched and in response to movement when he was repositioned. Interviews at that time with Nurse Aides 2 and 3 revealed that they were aware that the resident had pain during care. Observations during care provided to the resident on 11/13/13 from 9:05 a.m. to 9:15 a.m. revealed that during turning and provision of wound care to his coccyx area, the resident verbalized pain to the staff providing care. When he was turned to his right side by Nurse Aide 4 he moaned, and when Registered Nurse 10 touched the dressing on his coccyx area the resident stated, "It hurt, ow, ow; it hurt, give it a rest." Registered Nurse 10 proceeded to provide wound care and throughout this care the resident continued to moan and stated, "Ow, ow, ouch, oh, oh, oh, ow; it hurts; it still hurts." After the wound care was completed, the resident was placed on his back and when his legs were lifted to be placed on a wedge cushion, he again stated, "Ow, ow, oh; it hurts." Observations on 11/13/13 at 9:30 a.m. revealed that Nurse Aides 2 and 9 positioned the resident on his left side and during this care he indicated that he had pain stating, "Ow, ow, ow." Interview with Nurse Aide 2 on 11/13/13 at 10:40 a.m. revealed that the resident always complained of pain with any type of care such as touching or moving him. Interview with the Licensed Practical Nurse 5 on 11/13/13 at 11:45 a.m. revealed that she was not notified that the resident had pain with care that a.m. Interview with Registered Nurse 10 on 11/13/13 at 11:55 a.m. revealed that she did not know the resident's care plan related to pain, and she should have stopped care and determined his needs for pain relief prior to proceeding with the wound care. The facility's policy regarding documentation in the electronic health record, dated October 2013, indicated that all vital signs were to be documented in the resident's electronic health record. Physician orders, dated 10/18/13, for Resident R12 included an order for [REDACTED]. Staff were to hold the medicine if the systolic blood pressure (the top number of a blood pressure measurement) was less than or equal to 95 milligrams of mercury (mg/Hg). The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Observations during a medication pass on 11/12/13 at 4:28 p.m. revealed that Licensed Practical Nurse 6 administered 50 milligrams of [MEDICATION NAME] HCL to Resident R12 without first checking the resident's blood pressure. Interview with Licensed Practical Nurse 6 on 11/12/13 at 5:50 p.m. confirmed that the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with Licensed Practical Nurse 8 on 11/13/13 at 12:00 p.m. revealed that no nursing staff had documented the resident's blood pressure values since 10/23/13. 28 Pa Code 211.12 (d)(5) Nursing services.