Every finding on record at Concordia of the South Hills

Based on review of clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels for two of seven residents reviewed (Residents R1, and R12) Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it ' s untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included diabetes, legal blindness (severe visual impairment that cannot be corrected with glasses or contacts), and high blood pressure. Review of Resident R1 Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 1/29/25, indicated the diagnoses remain current. Review of Resident R1 physician ' s order revealed the following orders: - An order dated 5/9/24, oral hypoglycemia protocol: If blood glucose is less than 70 mg/dl and resident is able to swallow, administer 4 ounces (oz) of high-calorie shake; if unable to swallow follow emergency glucagon order, recheck blood glucose level in 15 minutes. If blood glucose remains below 70, contact MD (doctor). - An order dated 5/9/24, accu-check every 15 minutes as needed for signs and symptoms of low blood sugar. If blood glucose is less than 70 mg/dl and resident is able to swallow, administer 4 ounces (oz) of high-calorie shake, recheck blood glucose level in 15 minutes, if unable to swallow - administer glucagon per MD order. - An order dated 5/9/24, glucagon emergency injection kit 1 mg give if blood glucose less than 70 and resident unable to swallow/unconscious. recheck blood glucose in 15 minutes, if less than 70 (after glucagon administration) call 911. - An order dated 5/30/24, Humalog (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) 4 units in morning, hold if accucheck less than 70. - An order dated 12/2/24, Humalog 4 units before lunch and dinner. - An order dated 12/2/24, Humalog sliding scale 341-400 = 6 units. - An order dated 10/15/24, glargine (long-acting type of insulin that works slowly, over about 24 hours) 12 units in the morning. - An order dated 10/15/24, glargine 8 units at 6 pm (resident's preferred time). Review of the clinical record, and electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: - On 12/8/24, at 6:33 a.m. the CBG was noted to be 58. - On 2/5/25, at 6:34 a.m. the CBG was noted to be 60. Review of the care plan dated 1/8/24, indicated the following interventions: Provider follow up as needed. Resident will receive medications as ordered. Staff will cue resident to comply with measures to maintain blood sugars within desired range. Staff will evaluate resident for sign and symptoms of hyper-/hypoglycemia. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, staff failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of a clinical record indicated Resident R12 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and anxiety. Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of Resident R12 physician ' s orders revealed the following orders: - An order dated 12/26/24, oral hypoglycemia protocol: If blood glucose is less than 70 mg/dl and resident is able to swallow, administer 4 ounces (oz) of high-calorie shake; if unable to swallow follow emergency glucagon order, recheck blood glucose level in 15 minutes. If blood glucose remains below 70, contact MD (doctor). - An order dated 12/26/24, accu-check every 15 minutes as needed for signs and symptoms of low blood sugar. If blood glucose is less than 70 mg/dl and resident is able to swallow, administer 4 ounces (oz) of high-calorie shake, recheck blood glucose level in 15 minutes, if unable to swallow - administer glucagon per MD order. - An order dated 12/26/24, glucagon emergency injection kit 1 mg give if blood glucose less than 70 and resident unable to swallow/unconscious. recheck blood glucose in 15 minutes, if less than 70 (after glucagon administration) call 911. - An order dated 2/10/25, Humalog sliding scale 0-70 = 0 units initiate hypoglycemic protocol; 451-999 = call MD. - An order dated 12/26/24 through 3/24/25, glargine 35 units at bedtime. - An order dated 3/24/25, glargine 40 units at bedtime. Review of the clinical record, and electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: - On 3/9/25, at 3:57 p.m. the CBG was noted to be 521. - On 3/10/25, at 5:52 a.m. the CBG was noted to be 65. - On 3/21/24, at 11:23 a.m. the CBG was noted to be 549. - On 3/28/24, at 10:23 p.m. the CBG was noted to be 591. Review of the care plan dated 8/13/24, indicated the following interventions: Provider follow up PRN (as needed). Resident will received medications as ordered. Staff will evaluate resident for signs and symptoms of hyper-/hypoglycemia. Review of Resident R12's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, failed to follow interventions of the care plan, blood sugar was not rechecked, and the physician was not notified of abnormal results. During an interview on 4/4/25, at 9:15 a.m. Licensed Practical Nurse (LPN) Employee E1 stated she would follow the ordered sliding scale. If the reading was low, she would give juice or a snack, recheck the blood glucose and call the doctor. If the reading was high, she would call the doctor for orders, recheck the blood glucose, and document. During an interview on 4/4/25, at 9:45 a.m. LPN Employee E2 stated she would follow the sliding scale, and if there was not a sliding scale , she would follow facility policy. During an interview on 4/4/25, at 10:45 a.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition, failed to document an assessment or interventions used related to blood glucose, and failed to follow physicians orders for Residents R1 and R12. She stated the facility does not have policies regarding diabetic care of the residents, the facility follows nursing standards of below 70 and greater than 400, unless otherwise ordered. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(d) Resident Rights 28 Pa. Code 211.10 (c)(d) Resident Care policies 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on review of manufacturer ' s guidelines, observations, and staff interview, it was determined that the facility failed to make certain that medications and medication supplies were properly stored and/or disposed of in one of two medication rooms (First-floor medication room) and one of one medication carts (First-floor medication cart). The facility failed to make certain medication rooms were secured for one of two medication rooms (Second Floor Medication room). Findings include: Review of the facility policy Medication Storage dated [DATE], indicated the facility will ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations. The policy further stated all medication rooms are routinely inspected for discontinued and outdated medications, which would be destroyed. Review of the facility policy Medication Storage dated [DATE]. indicated the facility will ensure all medications will be stored in med rooms according to manufacturers recommendations sufficient to ensure proper sanitation, light and security. Review of the facility provided document Medication Storage in the facility - expiration dates other than the manufacturer's, updated [DATE], indicated that ophthalmic medications have an expiration date 28 days from the date opened. During an observation of the First-floor medication room on [DATE], at 10:50 a.m. revealed the following: -(11) bottles of glucometer testing control solution with an expiration date of [DATE]. -(3) bottles of glucometer testing control solution with an expiration date of [DATE]. -(11) bottles of glucometer testing control solution with an expiration date of [DATE]. -(9) colostomy barriers with an expiration date [DATE]. -(9) colostomy pouches with an expiration date [DATE]. -(2) colostomy pouches with an expiration date [DATE]. -(5) urinary pouches with an expiration date ,d+[DATE]. -(28) ostomy pouches with an expiration date ,d+[DATE]. -(8) ostomy pouches with an expiration date [DATE]. During an interview on [DATE], at 11:20 a.m. Licensed Practical Nurse Employee E1 confirmed the above expired items. During an observation of the First-floor medication cart on [DATE], at 2:30 p.m. revealed the following: -(1) bottle of atropine ophthalmic solution, with an open date of [DATE], and no use-by date noted. -(1) bottle of prednisolone ophthalmic solution, with an open date of [DATE], with a use-by date of [DATE]. -(1) bottle of brimonidine ophthalmic solution, with an open date of [DATE]/24, with a use-by date of [DATE]. -(1) bottle of tobramycin ophthalmic solution, with an open date of [DATE], and no use-by date noted. During an interview on [DATE], at 2:35 p.m. Licensed Practical Nurse Employee E1 confirmed the above expired items. During an interview on [DATE], at approximately 12:15 p.m. the Nursing Home Administrator(NHA) confirmed that the facility failed to make certain that medications and medication supplies were properly stored and/or disposed of in one of two medication rooms (First-floor medication room) and one of one medication carts (First-floor medication cart). During an observation on [DATE], at 11:00 a.m., Housekeeping Employee E2 was exiting the second floor medication room after mopping. During an interview on [DATE], at 11:12 a.m., Licensed Practical Nurse Employee E3 stated that she had opened the door of the medication room for Housekeeping Employee E2 and did not know that he was not authorized to be in the room without authorized staff. During an interview on [DATE], at 11:48 a.m., the NHA and Corporate Director of Nursing confirmed that the facility failed to make certain medication rooms are secured. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.9 (a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess residents for hypoglycemia (low blood glucose), failed to document and/or institute interventions for hypoglycemia, and failed to document notification to physicians of decreased capillary blood glucose (CBG) levels for one of three residents (Residents R154). Findings include: Review of the facility Hypoglycemia Protocol dated 8/3/23, indicated for conscious persons with a CBG level: - less than 45 mg/dl (milligrams per deciliter), to give 30 g (grams) of carbohydrates (8 ounces of juice or soda or 2 tablespoons jelly or sugar). Repeat CBG level in 15 minutes. - between 45-59 mg/dl, to give 20 g of carbohydrates (6 ounces of juice or soda or 1.5 tablespoons jelly or sugar). Repeat CBG level in 15 minutes. - between 60-100 mg/dl, to give 15 g of carbohydrates (4 ounces of juice or soda or 1 tablespoon jelly or sugar). Repeat CBG level in 15 minutes. Review of the facility policy Notification of Changes dated 8/3/23, indicated the facility will promptly consult with the resident's physician when there is a change requiring notification. Circumstances requiring notification include significant changes in the resident's physical, mental, or psychosocial conditions. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R154's Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 4/11/24, included diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of a physician's order dated 4/5/24, indicated to inject Humalog insulin (fast-acting medication to lower blood sugar levels) per sliding scale; if blood glucose is less than 70 initiate hypoglycemic protocol. Review of the Resident R154's blood sugar record revealed: -4/11/24, at 6:28 a.m. the CBG was 44 mg/dl. The clinical record failed to reveal documentation in a progress note addressing the low CBG level, failed to reveal the initiation of the hypoglycemic protocol, failed to reveal a recheck of the CBG level, and failed to reveal documentation of physician notification. -4/14/24, at 5:49 a.m. the CBG was 48 mg/dl. The clinical record failed to reveal a recheck of the CBG level and failed to reveal documentation of physician notification. -4/16/24, at 5:50 a.m. the CBG was 62 mg/dl. The clinical record failed to reveal documentation in a progress note addressing the low CBG level, failed to reveal the initiation of the hypoglycemic protocol, failed to reveal a recheck of the CBG level, and failed to reveal documentation of physician notification. During an interview on 4/18/24, at approximately 11:05 a.m. the Corporate Director of Nursing confirmed the facility failed to assess residents for hypoglycemia (low blood glucose), failed to document and/or institute interventions for hypoglycemia, and failed to document notification to physicians of decreased capillary blood glucose (CBG) levels for one of three residents. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for one of three residents (Resident R7). Findings include: Review of the facility policy Pressure Ulcer Protocol dated 8/3/23, indicated the facility will provide a program of prevention, care, and treatment of pressure ulcers to all residents to prevent skin breakdown and to promote healing. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 2/14/24, included the diagnoses of anemia (too little iron in the body causing fatigue) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section GG - Functional Abilities and Goals indicated that Resident R1 required partial/ moderate assistance to roll left and right. Review of the list of residents with pressure ulcers provided by the facility on 4/16/24, indicated Resident R1 had an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) on her left buttock, present upon her admission on 2/7/24. Review of Resident R7's clinical admission evaluation dated 2/7/24, indicated Resident R7 had skin warm & dry, skin color WNL (within normal limits), mucous membranes moist, turgor (ability of skin to change shape and return to normal) normal. This document further indicated Detailed documentation of skin issues can be completed within the COMS Skin Only Evaluation. Further review of Resident R1's clinical record revealed the skin only evaluation was not completed. Review of the section Body System Notes revealed Skin as unchecked. Review of the Braden Scale Assessment (a tool utilized to assess a patient's risk of developing a pressure ulcer) dated 2/7/24, revealed Resident R7 was at risk for the development of pressure ulcers. Review of Resident R7's baseline care plan dated 2/7/24, revealed the entry for pressure ulcer to be unchecked, and the need for wound care to be unchecked. Review of MDS dated [DATE], Section M - Skin Conditions indicated that Resident R7 had no current pressure ulcers. Review of Resident R7's physicians orders failed to reveal an order for treatment of pressure ulcers until 3/9/24, when an order was placed for care of a left buttock wound. Review Resident R7's care plan dated 2/7/24, for skin impairment, risk of impaired skin integrity, indicated Resident R1 will remain free of any new skin breakdown through next review date. Resident R7's care plan was updated on 3/12/24, to include an actual unstageable pressure ulcer of the left buttock. Review of a progress note dated 3/9/24, at 6:55 a.m. indicated an open area was noted on left medial buttocks. Review of a wound nurse practitioner's progress note dated 3/11/24, at 8:06 a.m. indicated Resident R7 is being seen for a new left buttock wound noted by the facility staff on 3/9/24. Review of Resident R7's clinical record revealed no Skin & Wound Evaluation assessments completed for the left buttock wound until 3/11/24. Review of Resident R7's Treatment Administration Record for April 2024, revealed no documentation for completion of Resident R7's left buttock wound treatment on 4/11/24 and 4/15/24. Review of progress notes for those dates failed to reveal information on the wound treatment's completion. Review of a physician's orders dated 2/7/24, indicated to Encourage to turn & reposition and Bed Wedge. Review of Resident R7's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff as of 4/16/24, indicated for staff to turn and reposition. During observations completed on: -4/16/24, at approximately 10:45 a.m., and 1:30 p.m. -4/17/24, at approximately 9:00 a.m., 11:30 a.m., 1:30 p.m., and 3:00 p.m. -4/17/24, at approximately 9:00 a.m., and 11:00 a.m. all revealed Resident R7 to be lying flat on her back, with her head slightly elevated. During the above observations, the bed wedge was noted to be on a chair in the room, not utilized. During an interview on 4/18/24, at approximately 11:05 a.m. the Corporate Director of Nursing confirmed the inaccuracy of the facility provided pressure ulcer list, confirmed the development of a new pressure ulcer for Resident R7, and was made aware of the lack of assistance from staff for Resident R7 to turn and reposition. During an interview on 4/18/24, at approximately 12:15 p.m. the Nursing Home Administrator confirmed the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for one of three residents. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on clinical record review and interviews with staff, it was determined that the facility did not develop a person-centered baseline care plan within 48 hours of a resident's admission related to infection control for two out of eight newly admitted residents (Resident R102 and Resident 201). Findings include: The facility Care plan summary policy dated 12/2/22, indicated that the facility will provide the resident with a written summary of the baseline care plan that includes resident's initial goals, summary of resident's medications, any services and treatments to be administered and any information based on the details of the comprehensive care plan. The care plan summary will be completed within 48 hours after admission. Review of Resident R102's admission record indicated he was admitted on [DATE]. Review of Resident R102's MDS assessment dated [DATE], indicated he was admitted with diagnoses that included Bacteremia (infection in the blood stream), Chronic Obstructive Pulmonary Disease (COPD-a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), Endocarditis(inflammation impacting the inner lining of the heart), and heart failure (a progressive heart disease that affects pumping action of the heart muscles). The MDS assessment indicated that these diagnoses were the most current upon review. Review of Resident R102's clinical admission assessment dated [DATE], indicated he had an infection upon admission. Review of Resident R102's physician orders dated 5/2/23, indicated to administer Ceftriaxone Sodium (antibiotic) intravenously every morning for 30 minutes until 5/31/23 for Bacteremia. Review of Resident R102's base line care plans did not include that he had an infection and was to receive an IV antibiotic treatment. During observations on 5/15/23, at 10:52 a.m. Resident R102 was observed in his room with use of IV antibiotic treatment in use and under isolation precautions. During an interview on 5/15/23, at 11:18 a.m. interview with Licensed Practical Nurse (LPN) Employee E1 stated that Resident R102 was still on IV antibiotic for an infection. Review of Resident 201's admission record indicated she was admitted on [DATE], with the diagnoses of diabetes, high blood pressure, and hyperlipidemia (high fats in the blood). Review of Resident 201's clinical admission assessment dated [DATE], indicated an IV (intravenous) catheter present to right antecubital (inner elbow area). Review of Resident 201's physician orders dated 5/12/23, failed to include orders for the presence and care of the IV catheter. Review of Resident 201's base line care plan did not include the presence and care of the IV catheter. During an observation on 5/15/23, at 10:03 a.m. Resident 201 was observed in her room with IV catheter to right antecubital area. During an interview on 5/16/23, at 1:45 p.m. the Director of Nursing (DON) confirmed the base line care plan and physician orders failed to include orders and care for the IV catheter. During an interview on 5/15/23, at 3:01 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to develop a person-centered baseline care plan within 48 hours of Resident R102's admission related to infection control as required and Resident 201's IV catheter care and maintenance. 28 Pa. Code 211.11(a)(b)(c)(d) Resident care plan.

Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to assess and properly manage surgical wound characteristics for one of four closed records (Resident CR153). Findings include: Review of the facility policy Documentation of Wound Treatments dated 10/17/22, indicated the following elements are documented as part of a complete wound assessment: -The type of wound (pressure injury, surgical, etc.) and anatomical location -Measurements: height, width, depth, undermining, tunneling -Description of wound characteristics. Review of the admission record indicated Resident CR153 admitted to the facility on [DATE]. Review of Resident CR153's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/20/23, indicated the diagnoses of right hip fracture, high blood pressure, and hyperlipidemia (high fats in the blood). Review of Resident CR153's care plan dated 1/17/23, indicated wound to right outer thigh - monitor for signs and symptoms of infection including: pain, fever, drainage, and periwound (surrounding area of wound). Review of Resident CR153's physician orders dated 1/13/23, indicated do not remove Aquacel dressing (absorbent wound treatment) until 1/20/23. Cleanse right outer thigh surgical dressing with normal sterile saline, apply a dry dressing daily and as needed to start on 1/20/23. Review of Resident CR153's progress note dated 1/13/23, indicated patient has two surgical incisions covered by an Aquacel dressing to the right outer thigh. Review of remaining progress notes from 1/13/23 -1/24/23 failed to include any mention of right outer thigh surgical wound. Review of Resident CR153's Treatment Administration Record (TAR) dated January 2023 indicated that the right outer thigh dry dressing was changed on 1/20/23 - 2/24/23 and findings were within normal limits. Review of the clinical record to include Physician orders, progress notes, care plan, TAR, and discharge note failed to include any mention of sutures that were in place after Aquacel dressing was removed on 1/20/23 and failed to include instructions or inquiry to physician of when a removal date is warranted. Interview with the Director of Nursing and the Nursing Home Administrator on 5/16/23, at 1:45 p.m. confirmed the facility failed to assess and properly manage surgical wound characteristics for one of four closed records (Resident CR153). 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies, observations and staff interview it was determined that the facility failed to store all drugs and biologicals in a safe, secure and orderly manner for three residents (Resident R4, R15, and R200) on one of two nursing units (First floor). Findings include: Review of the facility policy Medication Storage in the Facility dated 8/5/22, indicated all medications and biologicals are stored safely, securely, properly, and are accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Review of Admission record indicated Resident R4 was admitted to the facility on [DATE], with the diagnoses of diabetes, heart failure (heart doesn't pump blood as well as it should), and atrial fibrillation (irregular heart rhythm). Observation on 5/14/23, at 8:44 a.m. of Resident R4's bed side stand indicated a bottle of Systane eye drops (medication used for dry eyes), unlocked and unattended. Review of Admission record indicated Resident R200 was admitted to the facility on [DATE], with the diagnoses of high blood pressure, sacroiliitis (painful condition to lower back, buttocks, and thighs), and malaise (general feeling of discomfort). Observation on 5/14/23, at 8:50 a.m. of Resident R200's nightstand indicated a box of Paxlovid (medication used for Covid infections), unlocked and unattended. Review of Admission record indicated Resident R15 was admitted to the facility on [DATE]. Review of Resident R15's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/16/23, indicated diagnoses of heart failure, high blood pressure, and atrial fibrillation. Observation on 5/14/23, at 9:10 a.m. of Resident R15's nightstand indicated a box of Chloraseptic medication (used for sore throat), unlocked and unattended. Interview and tour on 5/14/23, at 9:15 a.m. Licensed Practical Nurse (LPN) Employee E2 confirmed the above observations and that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for three residents (Resident R4, R15, and R200) on one of two nursing units (First floor). 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility documents, activity calendars, observations, and resident and staff interviews, it was determined that the facility failed to meet the activity needs for five of five confidential group residents (R300, R301, R302, R303, and R304) and 11 of 18 residents (Residents R4, R5, R7, R13, R21, R26, R31, R139, R140, R141, and R142). Findings include: A review of the facility's Skilled Nursing/Rehab Facility Handbook: Recreational Activities indicated Our Activity Department plans daily group and individual activities for you, with consideration given to your interest and your functional abilities. You can request assistance to get to and from activities if needed. A weekly activity schedule is posted on each nursing unit and each day's activities are listed on the bulletin boards throughout the facility. During a group interview on 5/26/22, at 11:00 a.m. 5 of 5 residents (Residents R300, R301, R302, R303, R304) indicated there were no staff directed activities on the weekends or evenings, and that they were bored. During an interview on 5/25/22, at 10:58 a.m., when asked about the activity program, Resident R13 stated, You have to make your own. During an interview on 5/25/22, at 12:24 p.m., when asked about the activity program, Resident R5 stated, All there is to do it eat. Observation of the Activities Calendar posted on the second-floor nursing unit on 5/25/22, indicated that on 5/25/22, at 2:30 p.m. a Happy Hour would be provided in the second-floor dining room. Observation of the second-floor dining room on 5/25/22, from 2:32 p.m. through 2:46 p.m. revealed the dining room to be empty, with no group activity taking place on the unit. Observation of the Activities Calendar posted on the second-floor nursing unit on 5/26/22, indicated that on 5/26/22, at 1:00 p.m. an art/coloring activity would be provided in both the first-floor and second-floor dining rooms, and an apple pie social at 2:00 p.m Observation of the second-floor dining room on 5/26/22, from 1:00 p.m. through 1:10 p.m. revealed the dining room to be empty, with no group activity taking place on the unit. During an interview on 5/26/22, at 1:10 p.m. Nurse Aide (NA) Employee E2 stated, Group activities stopped because of covid. During an observation on 5/26/22, at 1:15 p.m. Resident R21 had not had any coloring activity supplies given to her in her room. During an interview and observation on 5/26/22, at 1:18 p.m. Resident R31 had not had any coloring activity supplies given to her in her room. Resident R31 stated, No bingo. No nothing. Went to one musical night, but that was it. Other than that, you stay in your room. During an interview and observation on 5/26/22, at 1:22 p.m. when asked about the lack of activity program being provided as scheduled in the first-floor dining room, Licensed Practical Nurse Employee E5 stated that many times the activities department staff walks around and asks if the residents would like to participate in the activity before starting it. During on an interview on 5/26/22, at 1:25 p.m. Resident R4 stated she was not asked if she wanted to participate in an art activity, and was unaware of the upcoming apple pie activity. During on an interview on 5/26/22, at 1:28 p.m. Resident R139 stated he was not asked if he wanted to participate in an art activity, and was unaware of the upcoming apple pie activity. During on an interview on 5/26/22, at 1:30 p.m. Resident R142 stated he was not asked if he wanted to participate in an art activity, and was unaware of the upcoming apple pie activity. During on an interview on 5/26/22, at 1:33 p.m. Resident R140 stated she was not asked if she wanted to participate in an art activity, and was unaware of the upcoming apple pie activity. During on an interview on 5/26/22, at 1:34 p.m. Resident R141 stated she was not asked if she wanted to participate in an art activity, and was unaware of the upcoming apple pie activity. Resident R141 further stated that there are not many activities. During an observation on the first-floor nursing unit on 5/26/22, from 2:00 p.m., through approximately 2:30 p.m., no apple-pie was observed to be distributed to the residents, and no group activity was held in the first-floor dining room. During an interview on 5/26/22, at 3:16 p.m. the Activities Director Employee E3 stated that group activities were stopped due to COVID-19. When asked if she was aware that the facility has not had a COVID-19 positive resident in approximately fifteen months, Activities Director Employee E3 confirmed that she was aware. When asked why residents did not have the apple pie for the scheduled apple pie activity, Activities Director Employee E3 stated indicated a list provided by Activities Aide Employee E4, who was also present at the interview, of who was asked and provided apple pie. On 5/27/22, six residents were interviewed about the apple pie social, with three answering the following: During an interview on 5/27/22, at 9:44 a.m., when asked about the apple pie social yesterday (5/26/22), Resident R21 stated, No I had cherry pie on my dinner tray though. During an interview on 5/27/22, at 9:46 a.m., when asked about the apple pie social yesterday (5/26/22), Resident R26 stated, No, I didn't have pie, I don't know. During an interview on 5/27/22, at 9:49 a.m., when asked about the apple pie social yesterday (5/26/22), Resident R7 stated, No apple but I had cherry on my dinner tray. Review of Activity Calendar failed to include an activity called Specialized Dementia Program. Observation of Resident R2 5/25/22 at 10:00am and 2:00pm in room not in engaged in activity. Observation of Resident R2 on 5/26/22 at 2:00pm facing toward TV at the nursing station area not engaged in activity. During an interview on 5/27/22, at 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to meet the activity needs for five of five confidential group residents and 11 of 18 residents. Review of Activity Calendar failed to include an activity called Specialized Dementia Program. 28 Pa Code: 211.10(d) Resident care policies. Previously cited: 3/18/21.

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to develop individualized care plans for eight of eight residents (Resident R1,R2, R4, R5, R7, R13. R21, R26, and R139). Findings include: Review of the facility policy Care Planning dated 8/5/21, indicated the facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's needs. The policy further indicated that a comprehensive care plan will be initiated within seven days after the comprehensive resident assessment (MDS, Minimum Data Set, periodic assessment of resident care needs) is completed. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of the MDS completed on 5/5/22, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1's score to be 10, moderately impaired. Review of the admission record indicated Resident R4 was readmitted to the facility on [DATE]. Review of the MDS completed on 5/18/22, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R4's score to be 13, cognitively intact. Review of the admission record indicated Resident R5 was admitted to the facility on [DATE]. Review of the MDS completed on 4/17/22, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission record indicated Resident R7 was admitted to the facility on [DATE]. Review of the MDS completed on 4/19/22, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R7's score to be 13, cognitively intact. Review of the admission record indicated Resident R13 was admitted to the facility on [DATE]. Review of the MDS completed on 4/27/22, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R13's score to be 15, cognitively intact. Review of the admission record indicated Resident R21 was admitted to the facility on [DATE]. Review of the MDS completed on 5/7/22, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R21's score to be 15, cognitively intact. Review of the admission record indicated Resident R26 was admitted to the facility on [DATE]. Review of the MDS completed on 5/10/22, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed BIMS Summary Score revealed Resident R26's was unable to be assessed as the resident was rarely understood. Review of the admission record indicated Resident R139 was admitted to the facility on [DATE]. Review of the MDS completed on 5/17/22, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident 1391's score to be 15, cognitively intact. Review of the Activities care plans for each of the above residents revealed the following: Interventions: (Resident Name) can choose to keep up with the news (Resident Name) can go to daily exercise (Resident Name) can go to play bingo, cards, puzzles, etc (Resident Name) can participate in religious service or practices (Resident Name) will be able to be around animals such as pets (Resident Name) will be able to go outside to get fresh air when weather permits (Resident Name) will be able to listen to music (Resident Name) will be offered his/her favorite activities (Resident Name) will be offered to do activities with groups of people (Resident Name) will be offered to go on trips in the community (Resident Name) will be offered to participate in arts/crafts (Resident Name) will be offered to participate in cooking/baking groups (Resident Name) will have access to the internet (Resident Name) will have access to TV/Movies (Resident Name) will have books, newspaper, and magazines to read Review of Admission record indicates Resident R2 was admitted to the facility on [DATE]. Review of MDS completed on 3/8/22 indicates diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff assessment for Mental Status Section C of MDS indicates Resident R2 as a Severely impaired - never/rarely made decisions. Review of Resident R2's careplan indicates Staff will encourage attendance in a specialized dementia program group. Review of Activity Calendar failed to include an activity called Specialized Dementia Program. Observation of Resident R2 5/25/22 at 10:00am and 2:00pm in room not in engaged in activity. Observation of Resident R2 on 5/26/22 at 2:00pm facing toward TV at the nursing station area not engaged in activity. 05/27/22 10:30 AM Interview Activity Aide Employee E1 asked what does a specialty dementia activity group mean in relations to Resident R2's care plan, she stated I'm not the Director, but no I don't know what that means. During an interview on 5/26/22, at 2:45 p.m. the Nursing Home Administrator confirmed the facility failed to individualize care plans for eight of eight residents. 28 Pa. Code 211.11(d) Resident care plan. Previously cited: 3/18/21

Based on review of facility policy and clinical record review and interview with staff, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for two of 13 residents. (Resident R1 and R2) A review of the facility policy Transfer to Hospital dated January 8/5/21, indicated when residents are transferred to the hospital to observe and record vital signs, symptoms, and any significant changes in the resident's chart. A review of the facility policy Clinical Notes dated 8/5/21, indicated clinical notes will be complete, timely, and accurate. A review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a nurse note completed by Licensed Practical Nurse (LPN) Employee E1 dated 3/15/22, indicated Resident R1 was sent to the hospital. The clinical record did not include vital signs, symptoms, or significant changes for resident R1. During an interview on 3/29/22 at 10:45 a.m., LPN Employee E1 stated on 3/15/22, Resident R1, had stable vital signs, was drowsy, had some speech changes, and confusion from baseline and this was not documented in the clinical record. A review of a physician order sheet dated February and March 2022, indicated Resident R1 was to have a bed alarm, chair alarm, and low bed daily each shift. During an interview, on 3/29/22 at 12:45 p.m., the Director of Nursing (DON) revealed bed alarms, chair alarms and low bed application is documented in the resident Flow Sheets. A review of the Flow Sheets for Resident R1 dated February and March 2022, did not include documentation that the bed alarm, chair alarm, and low bed were applied each shift daily from 3/23/22 through 3/15/22 and 3/24/22 through 3/29/22. A review of the clinical record indicated Resident R2 was admitted to the facility on [DATE] and discharged on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a physician order dated 3/11/22, indicated Resident R2 was to have a bed alarm, chair alarm, and low bed daily each shift. A review of the Flow Sheets for Resident R2 dated 3/11/22 through 3/18/22 did not include documentation that the bed alarm, chair alarm, and low bed were applied each shift daily. During an interview on 3/29/22 at 1:45 p.m., the DON confirmed the above findings and the facility failed to make certain that the medical record for Residents R1 and R2 were complete and accurately documented. 28 Pa. Code: 211.5(f)(g)(h) Clinical records.

Based on review of clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan plans that included specific and individualized plans of care for one of 15 residents (Resident R1). Findings include: Review of the clinical face sheet indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the plan of care dated 2/23/21, failed to indicate Resident R1 was taking a blood thinner or contain an individualized plan of care to ensure staff are assessing and monitoring for adverse reactions to the medication. During an interview on 3/18/21, at 1:24 p.m. the Licensed Practical Nurse Assessment Coordinator Employee E4 confirmed that the plan of care for Resident R1 did not include specific individualized care for assessing or monitoring for adverse effects of the medication. 28 Pa. Code 211.11(d) Resident care plans. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 28 Pa. Code 211.12(d)(2) Nursing services.

Based on review of facility policy, observation, interview, and manufacturer guidelines, the facility failed to ensure medications were secured properly in one of two medication carts (first floor) and failed to dispose of expired medications in one of two (second floor) medication rooms. Findings include: Facility policy Medication storage in the facility dated 1/2/21, indicates that medications and biologicals are stored safely, securely, and properly, following manufacturers recommendations or those of the supplier. The medication is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Manufacturer's recommendations of [MEDICATION NAME] ([MEDICATION NAME] Purified Protein Derivative) instruct a vial of [MEDICATION NAME] which has been entered and in use for 30 days should be discarded. During a second floor medication room observation on 3/16/21, at 10:28 a.m., two vials of [MEDICATION NAME] were noted to be opened and dated 1/23/21. During an interview at that time, RN Employee E3 confirmed the [MEDICATION NAME] vials were opened and expired and should have been discarded. During an observation of medication administration on 3/17/21, at 8:15 a.m., Registered Nurse (RN) Employee E2 failed to securely lock the medication cart left in the hallway while administering medications in a resident room. During an interview at that time, Employee E2 confirmed that the medication cart was left unlocked and accessible to unlicensed personnel. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 12/19/18, 9/18/19, 1/6/20 28 Pa. Code: 211.9(a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(3)(5) Nursing services.

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to maintain infection control practices to prevent the potential for cross contamination during a dressing change for one of 15 residents (Resident R3). Review of the facility policies Infection Prevention and Control Program dated August 5, 2020, indicates policies, procedures and aseptic practices are followed by personnel in performing procedure and in disinfection of equipment. During a dressing change observation on 3/17/21, at 9:31 a.m., RN Employee E1 failed to sanitize the overbed table prior to placing a barrier on it for dressing supplies. During an interview on 3/17/21, at 9:59 a.m., RN Employee E1 confirmed the above observation and confirmed that the dressing change had the potential of cross contamination. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies, observations and staff interviews, it was determined that the facility failed to make certain that pots, large pans, cups, dishes and eating/serving utensils were thoroughly sanitized to prevent the potential for cross contamination in the main kitchen of the facility. Findings include: The facility policy 3 Compartment Sink Compliance dated 8/5/19, instructed dietary staff to fill the sanitizing sink 2/3 full with warm water and then fill with sanitizer at 200 parts per million (PPM-concentration needed for proper sanitization), check with test strips to ensure solution compliance, document PPM reading on log and change the solution as needed. During an observation in the main kitchen on 1/13/20, at 8:45 a.m. dietary employees were using the 3-compartment sink. Review of the facility Dishwashing/Warewashing Machine Temperature Log sheet for January 2020, indicated that the sanitizer level for the 3-compartment sink was only checked one time/day. During an interview on 1/13/20, at 8:50 a.m. the Director of Food Services Employee E3 confirmed that the facility utilized the 3-compartment sink after all three meals but only checked the concentration in the sanitizing sink one time a day and that the facility failed to check the concentration prior to each use to make certain the solution was at the proper sanitization level to prevent the potential for cross contamination. The facility policy Seven Hazardous Analysis Critical Control Points dated 8/5/19, instructed dietary staff to make certain the appropriate wash and rinse temperatures were reached on the dish machine as per the manufacturer specifications. The metal specifications plaque on the American Dish Service dish machine utilized at the facility instructed that the temperature of the final rinse for high temperature machines needed to be at least 1[AGE] degrees Fahrenheit (°F). During an interview on 1/13/20, at 8:50 a.m. the Director of Food Services Employee E3 reported that the facility utilized a high temperature dish machine. During an observation of the dish machine on 1/15/20, at 8:50 a.m. Dietary Employee E4 was running the soiled breakfast dishes through the dish machine. The final rinse temperature reached 120°F. A second cycle was completed and the final rinse temperature was 122°F. During observations of multiple cycles of the dish machine on 1/15/20, from 8:51 a.m. to 9:35 a.m. the final rinse temperature never got higher than 138°F. During an interview on 1/15/20, at 9:40 a.m. the Director of Food Services Employee E3 confirmed that the facility failed to make certain that pots, large pans, cups, dishes and eating/serving utensils were thoroughly sanitized to prevent the potential for cross contamination. 28 Pa. Code: 211.6(c)(f) Dietary services. Previously cited 12/19/18.

Based on facility policy review, observation and staff interview, it was determined that the facility failed to secure medications on one of two medication carts (2nd floor nursing unit medication cart). Findings include: The facility policy Storage of Medication dated 1/2/20, indicated that medication carts were kept locked if they were not attended by persons with authorized access. During an observation of a medication pass on 1/14/20, at 8:15 a.m. Licensed Practical Nurse (LPN) Employee E2 prepared medications for Resident R20, entered the resident's room, closed the door without locking the medication cart. The medication cart was out of the view of LPN Employee E2 and its contents were accessible to residents, visitors and unlicensed staff who passed by in the hallway. During an interview on 1/14/20, at 8:20 p.m. LPN Employee E2 confirmed that the medications were not secured when he/she left the cart unlocked and out of view. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 9/18/19 and 12/19/18 28 Pa. Code: 211.10(c) Resident care policies.

Based on facility policy and clinical record review, observations and staff interview, it was determined that the facility failed to exercise proper infection control technique during a dressing change for one of two residents (Resident R1[AGE]). Findings include: The facility policy Dressing Change dated 8/5/19, indicated that nursing staff cleanse the wound with the prescribed solution, disposed of gloves, cleansed hands and donned a new pair of gloves to complete the dressing change. The Face Sheet indicated that Resident R1[AGE] was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician order [REDACTED]. During an observation of a dressing change on 1/14/20, at 10:35 a.m. Registered Nurse (RN) Employee E1 cleansed Resident R1[AGE]'s sacral wound with normal saline and then squirted Santyl ointment onto a gauze pad, applied the ointment with a cotton-tipped applicator and then covered the area with border gauze. RN Employee E1 failed to change gloves and perform handwashing after cleansing the wound and before applying the new dressing. During an interview on 1/14/20, at 10:55 a.m. RN Employee E1 confirmed the failure to exercise proper infection control technique during the dressing change for Resident R1[AGE]. 28 Pa. Code: 211.10(d) Resident care policies. Previously cited 9/18/19 and 12/9/18 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, incident report documentation, clinical records and staff interview, it was determined that the facility failed to provide adequate assistance with a transfer, resulting in actual harm (right tibial fracture) for one of six residents (Resident R1). Findings include: The facility lift limiting policy last reviewed 8/5/19, indicated any resident who is not able to bear weight to transfer or walk will always be lifted via mechanical lift unless contraindicated by a physician. High risk transfers include bed to chair transfers. Resident R1 admission documentation indicated she was admitted to the facility on [DATE]. Review of Resident R1 5-day Minimum Data Set assessment (MDS-periodic assessment of care needs) dated 8/22/19, indicated Resident R1 had [DIAGNOSES REDACTED]. Review of Section G0110B Transfer Section was coded 3-Self Performance and 3-Support indicating Resident R1 was a transfer extensive assistance with two person physical assistance. Review of Resident R1 care plan dated 8/15/19, indicated staff would transfer Resident R1 with assistance of two staff persons. The care plan indicated staff would maintain safety precautions as ordered. Review of a physician order [REDACTED]. Review of nurse progress notes dated 8/16/19, indicated Resident R1 was admitted after a c5-c6 spinal fusion (surgery to connect two or more vertebrae of the spine ). Review of a Resident R1 Physical Therapy assessment and plan of treatment document dated 8/16/19, indicated Resident R1 had impaired right and left hips and she needs maximum assistance of two staff persons for transfers. Review of a Resident R1 Physical Therapy notes dated 8/22/19, indicated Resident R1 was a maximum assistance of two persons with bed mobility and nursing staff is to use a hoyer lift. A facility incident report dated 8/24/19, indicated at 1:45 p.m. Nurse Aide (NA) Employee E2 attempted to transfer Resident R1 from her bed to a wheelchair, without additional assistance. Resident R1's legs gave out and she fell to the floor. Resident R1's right leg bent behind her. Resident R1's doctor and family were notified, and she was sent to the hospital. In the incident report, Nurse aid Employee E2 stated she received information that Resident R1 was a transfer assist of two-persons prior to the incident. Review of an X-ray report dated 8/24/19, indicated Resident R1 sustained a [MEDICAL CONDITION] tibial tuberosity (right knee bone). During an interview on 9/18/19, at 11:00 a.m. the Director of Rehabilitation Employee E3 stated that Resident R1 was recommended to be transferred with two staff person assistance. During an interview on 9/18/19, at 11:02 a.m. the Director of Nursing confirmed that the facility failed to provide adequate assistance with a transfer as per physician orders, resulting in actual harm to Resident R1 (fractured tibia). The facility failed to make certain Resident R1 was provided with adequate staff assistance during a transfer resulting in actual harm to the resident. 28 Pa Code: 201.18 (b)(1)(2) Management. 28 Pa Code: 201.29 (a) (c)(d)(j)(m) Resident Rights. 28 Pa Code: 211.10 (c)(d) Resident care policies. 28 Pa Code: 211.11 Resident care plan.

Based on facility policy review, observations and staff interviews, it was determined that the facility failed to have sufficient dietary staff to perform essential kitchen duties in the Main Kitchen. Findings include: The facility General Food Preparation and Handling policy dated 10/3/18, indicated that food items shall be prepared to conserve maximum nutritive value, develop and enhance flavor and to be free of injurious organisms and substances. Food will be prepared and served with clean tongs, scoops, spoons, spatulas, or other suitable implements so as to avoid manual contact of prepared foods. Use tongs or other serving utensils to serve bread or other items. Never touch food directly with bare hands. The facility Accuracy of Tray Line policy dated 10/3/18, indicated that tray line positions and set up procedures are planned for an efficient and orderly delivery system and that tray line positions for breakfast, lunch and dinner are determined and planned according to the menu, to operate at maximum efficiency and to obtain maximum accuracy. During tray line observation on 12/18/18, at 11:58 a.m. Head Cook Employee E1 plated four meals and placed them on an unheated surface above the steam table and replaced a plated meal when one was taken. Dietary Aide Employee E2 took an empty tray from the cart, placed a heated pallet on the tray, placed the plated food onto the heated pallet, and without changing gloves, obtained a dinner roll from a bag that was located on top of the food transportation cart, and proceeded to place the rest of the food and drink items on the tray and cover the meal with a lid and return the tray to the cart. Dietary Aide Employee E2 was responsible for all tray line assembly. During an interview on 12/18/18, at 1:30 p.m. the Nursing Home Administrator confirmed that having one person for tray assembly was insufficient to safely and accurately perform all tray line duties. The facility Cleaning dishes/Dish Machine policy dated 10/3/18, indicated that the person loading dirty dishes should not handle clean dishes unless apron is changed and hands are washed thoroughly before moving from dirty to clean dishes. During the dish machine/washing observation on 12/19/18, at 9:25 a.m. Dietary Aide Employee E3 was loading the dirty breakfast dishes into the washing machine without use of an apron and without donning a clean apron or performing hand washing removed a tray of clean dishes from the dish machine. During an interview on 12/19/18, at 9:30 a.m. the Director of Food Service Employee E4 confirmed that Dietary Aide Employee E3 was only to perform the loading of the dirty dishes and that there was no staff to assist with the removal of the clean dishes. 28 Pa. Code: 211.6 (c) Dietary services.

Based on review of facility policy and handbook, observation and staff interview, it was determined that the facility failed to provide the name and contact information of the grievance official and the procedure for filing a grievance for residents on two of two nursing units (1st and 2nd floor nursing units). Findings include: Review of the facility Grievances, Resident policy last reviewed 10/3/18, indicated that the Administrator or Designee would serve as the facility Grievance Official, that all resident grievances would be recorded on the Grievance/Complaint Log, and that residents would be notified of the outcome. During a review of the facility handbook provided to residents upon admission, the procedure for filing a grievance did not include the name of a grievance official and contact information, the time frame for getting it resolved, or the right to have a written response of the outcome. During a resident council meeting on 12/18/18, at 10:00 a.m., three of three residents were not aware of how to file a grievance at the facility. During an observation on 12/19/18, at 10:15 a.m. facility bulletin boards with resident information did not include the name or contact information for the grievance official with whom a grievance could be filed, a time frame when the grievance would be reviewed, or the right to receive written notification of the outcome. During an interview on 12/19/18, at 2:00 p.m. the Nursing Home Administrator confirmed that the facility bulletin boards and admission packet did not include the correct grievance procedure. 28 Pa. Code: 201.18 (e) (4) Management. 28 Pa. Code: 201.29 (i) Resident rights.

Based on facility policy review, observations and resident and staff interviews, it was determined that the facility failed to follow the displayed menu and failed to display menu changes for one of three lunch meals (12/18/18) and failed to provide meals in accordance with each resident's preference and in accordance with their select menu for four of 39 residents (Residents R4, R7, R15 and R26). Findings include: The facility Displaying the Menu policy dated 8/21/18, indicated that planned written menus will be posted by the dietary staff in a clear, obvious area that is easily accessible to residents, daily menus will be clearly posted outside the dining area on the menu board for residents, and food service staff is responsible for posting and revisions to the planed menu, which will be available to residents as soon as they are received and posted. During an interview on 12/17/18, at 1:06 p.m. Resident R15 indicated that the facility served her the wrong food and not what she had circled on her menu. During an interview on 12/17/18, at 2:20 p.m. Resident R7 indicated that the facility serves him the wrong food and not what he has circled on his menu. During an interview on 12/18/18, at 11:15 a.m. Resident R26 indicated that the facility serves him the wrong food and not what he has circled on his menu. During an interview on 12/18/18, at 11:36 a.m. Resident R4 indicated that the facility served him the wrong food and not what he had circled on his menu. The facility displayed menu on 12/18/18, was: Garden vegetable and pasta casserole, tossed salad with Italian dressing, bread slice, margarine, pears and lime Jello, decaf coffee and cranberry juice. The facility displayed alternate menu on 12/18/18, was: Chicken teriyaki, baked potato, butter, sour cream, applesauce, canned fruit, ice cream, decaf coffee, decaf hot tea and orange juice. During tray line observation on 12/18/18 at 11:58 a.m. the following items were changed: bread slice had been replaced with a dinner roll, individual snack size Jello in store container instead of pears and lime Jello, barbecued chicken instead of teriyaki chicken, and no sour cream, applesauce, canned fruit, orange juice or milk was provided. During an interview on 12/18/18, at 1:10 p.m. Director of Food Service Employee E4 confirmed that the menu items that were served did not match the facility displayed menu and that the displayed menus were not adjusted to reflect the changed menu items. 28 Pa Code: 211.6 (a) (b) (c) Dietary services.