Every finding on record at Conemaugh Memorial Medical Center Tcu

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure urinary output was monitored for one of 14 residents reviewed (Resident 27) who had a nephrostomy tube (a thin flexible tube inserted into the kidney through the skin to drain urine). Findings include: A facility policy for intake and output monitoring, dated March 19, 2025, input and output of residents are monitored during their stay at the facility. Intake and output are recorded on each resident in the electronic medical record every shift or per the physician's order if different from facility protocol. Output may include: output voided from the bladder, output from a urinary catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), or any other drainage tube in place to assist with bladder drainage, vomitus, or any large amount of fluid loss in any capacity. A nursing for Resident 27, dated March 6, 2026, revealed that the resident was admitted with diagnoses including a urinary tract infection, Chronic kidney disease stage 3a (mild-to-moderate loss of kidney function), chronic right ureteropelvic junction (UPJ) obstruction (a blockage where the ureter meets the kidney, causing trapped urine to damage the kidney), status post nephrostomy tube (recent placement of a nephrostomy tube), and was admitted for intravenous (administration of medications directly into a person's vein) antibiotic therapy. A care plan for the resident, dated March 6, 2026, revealed that the resident had a right nephrostomy tube and staff were to monitor strict intake and output measurement. Physician's orders for Resident 27, dated March 6, 2026, included an order to record intake and output three times daily. Review of Resident 27's clinical record revealed that there was no documented evidence that the resident's output, including his nephrostomy tube output, was documented on March 6 and 7 between the hours of 7:01 p.m. and 7:00 a.m.; on March 8 between the hours of 7:01 a.m. and 7:00 p.m.; and on March 9 between the hours of 7:01 a.m. and 7:00 p.m. Interview with the Director of Nursing on March 10, 2026, at 11:55 a.m. confirmed that there was no documented evidence that Resident 27's intake and output, including his nephrostomy output, was documented during the 12-hour shifts on the above-mentioned dates and times. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that dietitian recommendations for dietary supplements were accurately ordered for one of 14 residents reviewed (Resident 28).Findings include: Review of Resident 28's admission orders and progress notes, dated March 5, 2026, revealed that the resident was admitted after a fall at home resulting in a fracture to her left arm. A care plan for the resident, dated March 5, 2026, revealed that the resident had a risk for altered nutrition and skin integrity. A dietician note for Resident 28, dated March 5, 2026, at 8:29 a.m. recommended the addition of an ensure plus high protein supplement and a mighty shake supplement each daily to support adequate nutrition status. A physician's order for Resident 28, dated March 5, 2026, revealed that the resident was to receive an ensure high protein supplement daily with supper and a mighty shake supplement daily with lunch. Observations of Resident 28 on March 9, 2026, at 11:57 a.m. revealed that the resident was sitting in her chair in her room. She had a cast to her left arm, bruising to left the side of her face, and had a pressure-relieving cushion on her chair. She had received her lunch tray and there was no mighty shake on her tray. Review of Resident 28's clinical record revealed that there was no documented evidence that the resident received her supplements as recommended and ordered on March 7 for lunch and supper and March 8 for lunch and supper. Interview with Registered Nurse 1 on March 9, 2026, at 12:30 p.m. confirmed that Resident 28 was ordered to receive a mighty shake daily with lunch and an ensure high protein supplement daily with supper. Review of the order revealed that the order was entered incorrectly indicating that the order was entered for the resident to receive the supplements for one occurrence; however, she was to receive the supplement routinely as recommended by the dietician. Interview with the Director of Nursing on March 9, 2026, at 2:59 p.m. confirmed that the orders for Resident 28's supplements were entered into the electronic health record incorrectly and confirmed that the resident did not receive her supplements as ordered and recommended on March 7 for lunch and supper, March 8 for lunch and supper and on March 9 for lunch and she should have. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on a review of facility policies, clinical records, and facility investigation reports, as well as observations and staff interviews, it was determined that the facility failed to ensure resident safety during transportation in a wheelchair for one of 40 residents reviewed (Resident 216). Findings include: A facility policy regarding safe mobility, dated March 15, 2024, indicated that the facility would promote safe mobility for all residents in their care. Yellow code was caution, the resident needs assistance with mobility. A review of the clinical record for Resident 216 indicated that the resident was admitted to the facility on [DATE], with a diagnosis of a closed non-displaced intertrochanteric fracture of the right femur. Resident 216 was coded yellow. A mobility care plan for Resident 216, dated February 12, 2025, indicated that the resident was to have therapeutic exercise, bed mobility gait training, and transfer and ambulation devices as ordered. The resident was weight bearing as tolerated to the right lower extremity. A certified physician's assistant note for Resident 216, dated February 12, 2025, revealed that the resident had active problems that included a distal radius fracture of the right upper extremity with splint and a right femur fracture. The resident had an open reduction and internal fixation (surgical procedure used to treat broken bones) on February 8, 2025. Observations on February 20, 2025, at 1:15 p.m. in the therapy room revealed that Occupational Therapist 2 pushed Resident 216 into the therapy room. Resident 216's wheelchair did not have foot rests in place and her feet were approximately one inch off the ground. Resident 216 was pushed to the table to work on a hand coordination activity with a board and plastic pins. Interview with the Occupational Therapist 2 at the time of the observation revealed that Resident 216 had foot rests and they should be in use. Interview with Director of Nursing on February 20, 2025, at 12:44 p.m. confirmed that the staff should always use leg/footrests on wheelchairs when residents are being transported in their wheelchairs but indicated that therapy staff have their own procedure. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during the administration of medications for one of 15 residents reviewed (Resident 116). Findings include: The facility's policy regarding medication administration, dated March 15, 2024, indicated that medications are administered in accordance with professional standards of practice, in a manner to prevent contamination or infection. Staff will follow all infection control practices for hand hygiene and application of personal protective equipment as indicated. Physician's orders for Resident 116 included an order for the resident to receive 8.6 milligrams of Sennosides glycoside two tablets daily for constipation. Observations on February 19, 2025, at 8:45 a.m. revealed that Registered Nurse 1 dropped a tablet of Sennosides glycoside onto the medication cart. She picked the medication up off the cart with her bare hands and placed it into the medication cup and administered the medications to the resident. Interview with Registered Nurse 1 at that time confirmed that she should have wasted the medication. Interview with the Nursing Home Administrator on February 19, 2025, at 3:15 p.m. confirmed that medications that were dropped should have been wasted and were not to be touched with bare hands. 28 Pa. Code 211.12(d)(1)(5) Nursing 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 a safety assessment was completed for side rail use for one of 12 residents reviewed (Resident 163). Findings include: The facility's policy regarding side rails, dated March 15, 2024, indicated that the facility would promote a person-centered approach when determining the need and/or use of grab bars and side rails, which would include an assessment of the resident, medical condition, decision-making ability, and a review for possible entrapment and/or injury from use of a bed rail. Observations of Resident 163 on March 25, 2024, at 9:58 a.m. and March 26, 2024, at 8:20 a.m. revealed that the resident's bed was equipped with bilateral side rails. There was no documented evidence that Resident 163 was assessed for potential safety hazards prior to the side rails being applied to the resident's bed. Interview with the Director of Nursing on March 26, 2024, at 11:25 a.m. confirmed that there was no safety assessment completed for the use of side rails for Resident 163. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to obtain weights as ordered by the physician for eight of 11 residents reviewed (Residents 2, 6, 7, 9, 10, 12, 13, 14). Findings include: The facility's policy for weights, dated March 16, 2023, indicated that upon admission, residents would have an admission weight done to record baseline weight. Residents will then be set up on a biweekly weight schedule unless otherwise ordered by physician or deemed necessary by registered nurse. All weights would be documented in the electronic record and on the report sheet. Physician's orders for Resident 2, dated March 22, 2023, included and order for the resident to be weighed every Wednesday and Saturday. A review of Resident 2's weight records from admission on March 23, 2023, to April 5, 2023, revealed that the resident was not weighed three out of three days. Physician's orders for Resident 6, dated March 29, 2023, included an order for the resident to be weighed daily. A review of Resident 6's weight records from admission on March 29, 2023, until April 5, 2023, revealed that the resident was not weighed seven out of seven days. Physician's orders for Resident 7, dated March 28, 2023, included an order for the resident to be weighed on Tuesdays and Fridays. A review of Resident 7's weight records from admission on March 28, 2023, to April 5, 2023, revealed that the resident was not weighed two out of two days. Physician's orders for Resident 9, dated March 25, 2023, included an order for the resident to be weighed on Wednesday and Saturdays. A review of Resident 9's weight records from admission on March 25, 2023, to April 5, 2023, revealed that the resident was not weighed three out of three days. Physician's orders for Resident 10, dated March 18, 2023, included an order for the resident to be weighed on Wednesday and Saturdays. A review of Resident 10's weight records from admission on March 18, 2023, to April 5, 2023, revealed that the resident was not weighed five out of five days. Physician's orders for Resident 12, dated March 30, 2023, included an order for the resident to be weighed every Monday and Thursday. A review of Resident 12's weight records from admission on March 31, 2023, to April 5, 2023, revealed that the resident was not weighed two out of two days. Physician's orders for Resident 13, dated March 21, 2023, included an order for the resident to be weighed every Tuesday and Friday. A review of Resident 13's weight records from admission on March 23, 2023, to April 5, 2023, revealed that the resident was not weighed four out of four days. Physician's orders for Resident 14, dated March 24, 2023, included an order for the resident to be weighed on Tuesdays and Fridays. A review of Resident 14's weight records from March 24, 2023, to April 5, 2023, revealed that the resident was not weighed four out of four days. Interview with the Director of Nursing on April 5, 2023, at 9:20 a.m. confirmed that Residents 2, 6, 7, 9, 10, 12, 13 and 14 should have been weighed per their physician's orders and they were not. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly stored in the medication cart. Findings include: A policy for Pharmacy Services, dated March 16, 2023, indicated that medications should be secured in the proper medication cart for administration. Observations during medication administration on April 5, 2023, at 7:50 a.m. revealed that Registered Nurse 1 prepared Atenolol 50 milligrams (mg), Bupropion 300 mg, Lexapro 10 mg, Metformin 1000 mg, and Potassium Chloride 10 milliequivalents (mEq) for Resident 9 and left the blister packs of medications unsecured and unattended on top of the medication cart while he entered the resident's room to administer the medications to the resident. When Registered Nurse 1 entered the resident's room, the medication cart was out of his line of sight and was left unlocked with the keys to the medication cart hanging in the lock. An interview with Registered Nurse 1 at that time revealed that he should have put all medication in the cart, locked the cart, and removed the keys prior to entering the resident's room. Interview with the Director of Nursing on April 5, 2023, at 12:10 p.m. confirmed that medications should not have been left unattended and unsecured on the medication cart and the medication cart should have been locked and the keys removed. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1) Nursing services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a written summary of the baseline care plan was provided to the resident and/or the resident's representative for 10 of 10 residents reviewed (Residents 2, 9, 61, 63, 64, 68, 69, 70, 72, 73) who were new admissions to the facility. Findings include: Resident 2's clinical record revealed that the resident was admitted to the facility on [DATE], and a baseline care plan was developed at that time. However, there was no documented evidence that the resident and/or the resident's representative received a written summary of the baseline care plan. Resident 9's clinical record revealed that the resident was admitted to the facility on [DATE], and a baseline care plan was developed at that time. However, there was no documented evidence that the resident and/or the resident's representative received a written summary of the baseline care plan. Resident 61's clinical record revealed that the resident was admitted to the facility on [DATE], and a baseline care plan was developed at that time. However, there was no documented evidence that the resident and/or the resident's representative received a written summary of the baseline care plan. Resident 63's clinical record revealed that the resident was admitted to the facility on [DATE], and a baseline care plan was developed at that time. However, there was no documented evidence that the resident and/or the resident's representative received a written summary of the baseline care plan. Resident 64's clinical record revealed that the resident was admitted to the facility on [DATE], and a baseline care plan was developed at that time. However, there was no documented evidence that the resident and/or the resident's representative received a written summary of the baseline care plan. Resident 68's clinical record revealed that the resident was admitted to the facility on [DATE], and a baseline care plan was developed at that time. However, there was no documented evidence that the resident and/or the resident's representative received a written summary of the baseline care plan. Resident 69's clinical record revealed that the resident was admitted to the facility on [DATE], and a baseline care plan was developed at that time. However, there was no documented evidence that the resident and/or the resident's representative received a written summary of the baseline care plan. Resident 70's clinical record revealed that the resident was admitted to the facility on [DATE], and a baseline care plan was developed at that time. However, there was no documented evidence that the resident and/or the resident's representative received a written summary of the baseline care plan. Resident 72's clinical record revealed that the resident was admitted to the facility on [DATE], and a baseline care plan was developed at that time. However, there was no documented evidence that the resident and/or the resident's representative received a written summary of the baseline care plan. Resident 73's clinical record revealed that the resident was admitted to the facility on [DATE], and a baseline care plan was developed at that time. However, there was no documented evidence that the resident and/or the resident's representative received a written summary of the baseline care plan. Interview with the Director of Nursing on May 18, 2021, at 5:15 p.m. revealed that the facility was not aware that they were to be providing each resident and/or their representative with a written summary of the baseline care plan. She confirmed that there was no documented evidence that a written summary of the baseline care plan was provided to any of the residents and/or the residents' representatives.

Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to maintain the dignity of one of 20 residents reviewed (Resident 61) who had an indwelling urinary catheter. Findings include: Physician's orders for Resident 61, dated May 13, 2021, included an order for the resident to have an indwelling urinary catheter (a tube inserted and held in the bladder to drain urine into a collection bag). Observations on May 17, 2021, at 1:00 p.m. revealed that the resident was being assisted to walk down the hallway using a walker, and with a physical therapy employee at his side. The resident's urinary catheter drainage bag was hanging from a hook on the bottom horizontal bar of the resident's walker, and it was approximately one-quarter full of yellow urine. Observations on May 17, 2021, at 3:39 p.m. and 3:58 p.m. revealed that Resident 61 was seated in a chair beside his bed, with the urinary catheter drainage bag lying uncovered on the floor in front of his feet. The resident had two visitors in his room at that time, and one was sitting directly across from and facing him. Interview with the Director of Nursing on May 17, 2021, at 3:58 p.m. confirmed that Resident 61's urinary catheter drainage bag did not have a cover or privacy bag on it, and it should have. She confirmed that catheter drainage bags should have a privacy cover on them at all times. 28 Pa. Code 201.29(j) Resident rights.

Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to ensure that the resident environment was as free from accident hazards as possible, by failing to complete an assessment to ensure that the use of an air mattress did not create safety hazards for one of 10 residents reviewed (Resident 69). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 69, dated May 5, 2021, revealed that the resident was cognitively impaired, required assistance with bed mobility and transfers, and had a Stage 1 pressure ulcer. Admission paperwork dated April 28, 2021, revealed that the resident was admitted to the facility that day with diagnoses that included right knee effusion (excessive fluid on the knee joint) and muscle weakness. An admission nursing note identified a Stage 1 pressure ulcer (skin impairment caused by pressure), and physician's orders, dated April 29, 2021, included an order for the resident to use a specific air mattress. An occupational therapy note for Resident 69, dated May 2, 2021, revealed that the resident needed assistance to move the right lower extremity when moving from a lying to a sitting position. There was no documented evidence that the use of an air mattress was assessed for Resident 69, to ensure that it did not create any safety hazards for the resident. Observations of Resident 69 on May 17, 2021, at 11:57 a.m. revealed that she was lying in her bed, which was equipped with an air mattress with top and bottom bolsters, and bilateral mobility bars (side rails). An interview with the Director of Nursing on May 20, 2021, at 12:45 p.m. confirmed that an air mattress safety assessment was not completed for Resident 69 prior to placing an air mattress on her bed. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to ensure that a resident with an indwelling urinary catheter received appropriate treatment to prevent urinary tract infections for one of 20 residents reviewed (Resident 61). Findings include: The facility's policy regarding urinary catheter use (a tube inserted and held in the bladder to drain urine), dated March 25, 2021, indicated that the facility was to provide quality care to prevent complications during urinary catheter use. A physician's admissions note for Resident 61, dated May 13, 2021, indicated that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Observations on May 17, 2021, at 3:39 p.m. and 3:58 p.m. revealed that Resident 61 was seated in a chair beside his bed, with the urinary catheter drainage bag lying uncovered on the floor in front of his feet. The resident had two visitors in his room at that time. Interview with the Director of Nursing on May 17, 2021, at 3:58 p.m. confirmed that Resident 61's urinary catheter drainage bag was in direct contact with the floor and it should not have been. She then asked the resident if he had placed his catheter bag on his garbage can and it fell off. One of Resident 61's visitors replied, It has been on the floor for the past five days when we visit. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was stored and prepared in accordance with professional standards for food service safety. Findings include: The facility's policy regarding dating and labeling food, dated March 25, 2021, indicated that food stored frozen should be kept no longer than 90 days, and any opened or prepared products should be labeled and dated using the culinary approved label. The facility's policy regarding managing food brought in from home, dated March 25, 2021, indicated that food items were to be placed in the refrigerator and kept for a maximum of three days, and after three days it was to be discarded. Residents and family were to be educated about this safety protocol. Observations of the walk-in freezer on May 17, 2021, at 10:14 a.m. revealed that there was a box of vegetable blend that was previously open and uncovered, and there were ice crystals in the box. There was also a box of puff pastry sheets that was open and uncovered. Neither of the boxes were labeled with date they were opened. Interview with Chef 1 confirmed that food items in the freezer were not to be left uncovered and open. Observations in the pantry on May 20, 2021, at 8:35 a.m. revealed that there was a container of [MEDICATION(S)] that was labeled for a specific resident and was dated May 15, 2021. Interview with the Dietary Director on May 20, 2021, at 9:24 a.m. confirmed that frozen foods were not to be open in the freezer, and should be labeled and dated. Interview with the Director of Nursing on May 20, 2021, at 11:45 a.m. confirmed that the [MEDICATION(S)] should have been discarded after three days, but the resident refused to let it be discarded. 28 Pa. Code 211.6(f) Dietary services.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was prepared and distributed in accordance with professional standards for food service safety by failing to ensure that dietary staff wore proper hair restraints. Findings include: The facility's policy regarding uniforms, dated August 2019, indicated that team members working with food should wear approved hair restraints while on duty, and the only exception was to remove hair restraints when delivering trays to residents. Observations in the kitchen during breakfast preparations on February 18, 2020, at 7:42 a.m. and during lunch preparations at 11:28 a.m. revealed that Cook 1 was placing food onto residents' meal trays while wearing a hat that did not cover all of her hair in the front of her head. Interview with the Director of Food and Nutrition on February 18, 2020, at 11:48 a.m. confirmed that Cook 1's hair was not entirely covered by her hat. 28 Pa. Code 211.6(f) Dietary services.

Based on observations and staff interviews, it was determined that the facility failed to maintain a clean and sanitary environment in the kitchen and to label and date opened food items. Findings include: Observations in the walk-in freezer on (MONTH) 12, 2019, at 9:24 a.m. revealed that there was an opened 12-pack of what appeared to be chocolate muffins; the package was opened and not resealed, leaving the muffins exposed to the air, and the package was not labeled with the date it was opened. There was also an opened case of chocolate Mighty Shakes (a nutritional supplement) that contained 16 unopened shakes, with one shake container that appeared to have been opened, or exploded, spilling its contents throughout the box and coating the other shakes in the box with a frozen brown liquid. Interview with the Manager of Food and Nutrition Services on (MONTH) 12, 2019 at 9:26 a.m. confirmed that the package of chocolate muffins should have been resealed and labeled with the date it was opened, and the case of Mighty Shakes should have been thrown away due to the condition of the spilled contents in the box. Observations in the walk-in vegetable cooler on (MONTH) 12, 2019, at 9:39 a.m. revealed that there were two rotten yellow squash sitting on top of a box full of zucchini squash, and a dead cockroach on the floor of the cooler just beneath the shelves where the tomatoes were being stored. Interview with the Manager of Food and Nutrition Services on (MONTH) 12, 2019, at 9:41 a.m. confirmed that the yellow squash were rotten and should have been thrown away, and the dead roach should have been disposed of and the floor should be sanitized. Observations in Dry Storage Area 1 on (MONTH) 12, 2019, at 9:43 a.m. revealed that approximately ten inches of cove molding had come off the wall and was lying on the floor. There was also a dead cockroach on the floor under the shelving where the boxed juices were stored. Observations in the plastic storage room on (MONTH) 12, 2019, at 9:44 a.m. revealed that there were three dead cockroaches on the floor. Interview with the Manager of Food and Nutrition Services on (MONTH) 12, 2019, at 9:44 a.m. confirmed that the cove molding needed repaired, and the dead cockroaches needed to be swept up and the floors properly cleaned. Observations during a follow-up visit to the kitchen on (MONTH) 14, 2019, at 10:10 a.m. revealed that the case of Mighty Shakes with the spilled contents throughout the box was still present in the freezer, the dead cockroach was still in the same place in the dry storage area, and there were more dead roaches in the meal cart storage area, under the dish drying rack, under a food prep table where the toaster was kept, and also in the food prep area under a large commercial mixer. The rotten yellow squash were still sitting on top of the box of zucchini in the vegetable cooler, and there was a foul odor noted. When the box of zucchini was moved, the shelving underneath it was noted to be dotted with areas of a black, removable substance. When the shelving was rolled away from the wall, the floor underneath had the same black speckled appearance, along with a build-up of debris on the floor that included crumbs, potatoes, and a pair of reading glasses. Interview with the Manager of Food and Nutrition Services on (MONTH) 14, 2019, at 10:26 a.m. confirmed that the above areas were not cleaned on Monday, (MONTH) 12, 2019, and they should have been. 28 Pa. Code 207.2(a) Administrator's responsibility. 28 Pa. Code 211.6(f) Dietary 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 intravenous catheter sites were changed every three days according to the facility's policy for one of 14 residents reviewed (Resident 64). Findings include: The facility's policy regarding intravenous catheters (a thin tube inserted into a vein and used for the administration of fluids and/or medications), dated (MONTH) 1, 2019, indicated that an intravenous catheter was to be placed upon an order of a physician, and the site was to be changed every three days or as ordered by the physician. physician's orders [REDACTED]. Resident 64's Medication Administration Records (MAR's) revealed that the last dose of [MEDICATION NAME] tazobactam and sodium chloride flush were administered on (MONTH) 8, 2019. Observations of Resident 64 on (MONTH) 12, 13, 14 and 15, 2019, revealed that the resident had two intravenous catheters in place, one in his right forearm and one in his left forearm. There was no documented evidence in the clinical record to indicate when the catheters were inserted, why there were two, and no documented evidence that the sites were changed every three days in accordance with the facility's policy. Interview with the Director of Nursing on (MONTH) 15, 2019, at 1:46 p.m. confirmed that there was no documented evidence in Resident 64's clinical record to indicate when the two intravenous catheters were inserted, as the dressings covering the catheters were not dated, but should have been. She confirmed that there was no documented evidence that the catheter site was changed every three days since (MONTH) 3, 2019, or that the catheters were used or flushed since (MONTH) 8, 2019, and that physician's orders [REDACTED]. 42 CFR 483.25(h) [MEDICATION NAME]/IV Fluids. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies and yearly performance evaluations for nurse aides, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on hire dates for five of nine nurse aides reviewed (Nurse Aides 1-5). Findings include: The facility's policy regarding performance appraisals, dated (MONTH) 1, 2019, indicated that yearly performance evaluations were to be completed no later than 30 days following the anniversary of a nurse aide's start date, if possible. A list of nurse aide performance evaluations provided by the facility revealed that based on their month and date of hire, annual performance evaluations were due between (MONTH) 1 and (MONTH) 9, (YEAR), for Nurse Aides 1-5. However, these nurse aides' performance evaluations were completed more than 30 days after the anniversary of their hire dates. Interview with the Director of Nursing on (MONTH) 15, 2019, at 2:00 p.m. confirmed that annual performance evaluations for Nurse Aides 1-5 were completed more than 30 days from the anniversaries of their hire dates. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.20(a)(c) Staff development.

Based on review of the Pennsylvania Nurse Practice Act, facility policies, and clinical records, as well as staff interviews, it was determined that the facility failed to clarify physician's orders [REDACTED]. Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. The facility's policy regarding medication administration, dated (MONTH) 3, (YEAR), revealed that the resident was to receive the right medication, at the right time, and in the right dose. physician's orders [REDACTED]. The orders did not include instructions for the staff to follow when the resident's pain scale rating was 4 to 7, and there was no evidence that the nursing staff attempted to clarify the orders with the resident's physician. A care plan, dated (MONTH) 30, (YEAR), indicated that pain medications were to be given as ordered. Resident 58's Medication Administration Record [REDACTED] An interview with the Director of Nursing on (MONTH) 4, (YEAR), at 11:29 a.m. confirmed that Resident 58's physician's orders [REDACTED]. physician's orders [REDACTED]. The resident's Medication Administration Record [REDACTED]. However, there was no documented evidence that the physician's orders [REDACTED]. Interview with the Director of Nursing on (MONTH) 4, (YEAR), at 10:46 a.m. confirmed that nursing staff should have administered the [MEDICATION NAME] and [MEDICATION NAME] to Resident 106 as ordered by the physician, or contacted the physician to clarify the order. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of manufacturer's directions, facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to label a multi-dose container of [MEDICATION NAME] serum with the date they were opened in one of two medication rooms reviewed. Findings include: The facility's policy regarding medication storage, dated (MONTH) 3, (YEAR), revealed that all medications would be stored according to manufacturer's recommendations or as directed by the pharmacist. The manufacturer's instructions for [MEDICATION NAME] ([MEDICATION NAME] purified protein derivative), dated (MONTH) (YEAR), revealed that a vial of [MEDICATION NAME], which had been in use for 30 days, should be discarded. Observations in the medication storage room on (MONTH) 4, (YEAR), at 1:20 p.m. revealed that a vial of [MEDICATION NAME] serum (used to test for [MEDICAL CONDITION] - a serious bacterial infection that mainly affects the lungs) was previously opened and not labeled with the date it was opened. Interview with Registered Nurse 1 at that time confirmed that the vial of [MEDICATION NAME] should have been dated when opened. Interview with the Director of Nursing on (MONTH) 4, (YEAR), at 1:28 p.m. confirmed that the multidose vials of [MEDICAL CONDITION] serum should have been labeled with the date they were opened. 28 Pa. Code 211.9(h) Pharmacy services. 28 Pa. Code 211.12(d)(1)Nursing services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that medications were obtained and provided as ordered by the physician for one of 11 residents reviewed (Resident R6). Findings include: admission orders [REDACTED]. physician's orders [REDACTED]. July 2017 revealed that Pravachol was not administered on July 3, 4, 5 or 6, 2017. The documentation on the MAR's revealed that the nurses were electronically requesting the medication from the pharmacy each day; however, as of 2:00 p.m. on July 6, 2017, the resident had not received the medication and the MAR's stated medication not available. Interview with the Director of Nursing on July 6, 2017, at 4:00 p.m. confirmed that Pravachol was not administered to Resident R6 and was documented as not available from the pharmacy on the above dates. The Director of Nursing noted at that time that the nurses were requesting the medication from the pharmacy; however, the pharmacy had not sent the medication and simply stated that it would arrive on the next delivery. 28 Pa. Code 211.9(a)(1) Pharmacy services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of 11 residents reviewed (Resident CR9). Findings include: admission orders [REDACTED]. physician's orders [REDACTED]. A nursing note for Resident CR9, dated April 4, 2017, revealed that the nurse held (did not give) the insulin when the resident stated that she was not feeling well and refused her night time snack. There was no documented evidence of the accucheck result. Interview with the Director of Nursing on July 6, 2017, at 4:00 p.m. confirmed that an accucheck result was not documented for Resident CR9 on April 4, 2017, at bedtime. The Director of Nursing stated that the facility's new computer documentation system did not have a particular spot for the accucheck results and therefore they were sometimes not documented. 28 Pa Code 211.5(f) Clinical records. Previously cited 8/31/16.