Every finding on record at Cornwall Manor

Based on facility policy review, clinical record review, observation, and staff interview it was determined that the facility failed to provide appropriate care for respiratory equipment for one of 18 sampled residents. (Resident 60) Findings include: Review of facility policy entitled, Oxygen Usage and Storage on Nursing Units, last reviewed on November 6, 2024, revealed that all respiratory therapy equipment was to be changed on a weekly basis. Clinical record review revealed that Resident 60 had diagnoses that included chronic respiratory failure with hypoxia (low oxygen level). On May 17, 2025 the physician ordered oxygen via nasal cannula at bedtime and as needed for labored breathing, dyspnea, and for comfort. On April 5, 2025, the physician ordered for staff to wipe down the concentrator, clean filters, replace humidification bottle, oxygen mask, nasal cannula, and plastic bags weekly on night shift and items should be marked with date of replacement. Observations on June 11, 2025, at 9:59 a.m. and on June 12, 2025, at 12:15 p.m., revealed that the oxygen tubing was dated May 25, 2025. In an interview on June 11, 2025, at 2:09 p.m., the Assistant Director of Nursing confirmed that the oxygen tubing should be changed weekly. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to provide behavioral health services for one of three sampled residents with mood and behavior concerns. (Resident 22) Findings include: Clinical record review revealed that Resident 22 had diagnoses that included anxiety. Review of the care plan revealed the resident had a history of suicidal ideation and alterations to psychosocial well-being with behaviors and delusions. The interventions were for staff to monitor the resident for anxiety, distress, and changed mood or behavior. Staff were to notify the resident's physician, provide social services case assistance, and interventions as needed. On July 26, 2024, staff noted that the resident had refused to go to bed or allow staff to provide incontinence care and stated that she just wanted to die. There was no evidence that staff notified social services or the resident's physician of the alteration in the resident's mood. In an interview on August 1, 2024, at 9: 49 a.m., the Director of Nursing confirmed that staff were to notify social services or the physician for changes in mood and there was no evidence that the resident's care team was made aware of the alteration in mood or that interventions were implemented. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately supervise residents who were at risk for wandering, elopement, and/or other behavioral symptoms for two of 19 sampled residents. (Residents 16, 73) Findings include: Review of the facility policy entitled, Elopement Assessment, Prevention, and Response, last reviewed November 9, 2022, revealed that an elopement is defined as when a resident leaves the premises without authorization. Clinical record review revealed that Resident 73 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's dementia, anxiety, and adjustment disorder. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had memory impairment and exhibited wandering behavior. Review of the care plan revealed the resident was at risk for elopement and walked independently without any assistive devices. Review of nursing documentation revealed that Resident 73 was attempting to leave the unit on May 19, 2023. On May 31, 2023, and June 6, 2023, a nurse noted that Resident 73 left the unit and was redirected back in by staff. On June 17, 2023, the resident was attempting to leave the unit. On June 18, 2023, a nurse noted that Resident 73 left the unit and was redirected back by staff. On June 27, 29, and 30, 2023, and July 4, 8, and 10, 2023, Resident 73 was attempting to leave the unit. On July 10, 2023, a nurse noted the resident left the unit and was redirected back by staff. On July 11, 12, 14, 17, and 22, 2023, the resident was again attempting to leave the unit. Review of an incident report dated July 22, 2023, revealed that at 3:50 p.m., Resident 73 was observed outside the main entrance of the building by the receptionist. Further review of facility documention, revealed that the resident had exited through the main unit doors, taken the elevator down to the first floor, and then exited the building. She then walked up the sidewalk around the side of the building to the main entrance where she was observed by the receptionist. The facility failed to provide adequate supervision in order to prevent an elopement. Clinical record review revealed that Resident 16 was admitted to the facility with diagnoses that included Alzheimer's disease and depression. Review of Resident 16's current care plan revealed that the resident wandered into other residents' rooms and had the potential to be physically aggressive towards other residents. Review of the nursing notes revealed that on April 28, 2023, June 22, 23, 24, 25, 26, and 29, 2023, and July 1, 5, and 8, 2023, Resident 16 was found in multiple residents' rooms. On May 2, 2023, a social services note indicated that the resident often wandered into other residents' rooms. Review of a facility incident report and nursing notes revealed that on July 3, 2023, the resident was found outside the unit patio outside the fence. Staff was unaware of the resident's location at that time. The facility failed to provide adequate supervision for Resident 16's elopement and wandering behavior. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident's physician and responsible party of a change in condition/injury for one of 19 sampled residents. (Resident 42) Findings include: Clinical record review revealed that Resident 42 had diagnoses that included Alzheimer's disease, chronic kidney disease, and hypertension (high blood pressure). Review of a nurse's note dated July 17, 2023, revealed that a bruise was observed on the resident's right forearm. There was no documentation to support that the resident's physician or responsible party were notified of the bruise. In an interview on July 28, 2023, at 12:54 p.m., the Director of Nursing confirmed that there was no documented evidence that the resident's physician or responsible party were notified of the change in condition/injury. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of 19 sampled residents. (Resident 5) Findings include: Clinical record review revealed that Resident 5 had diagnoses that included Alzheimer's disease, hypertension, and orthostatic hypotension. On November 13, 2022, a physician ordered that staff administer a medication (midodrine hydrochloride) three times a day to treat the resident's low blood pressure. Staff was not to give the medication if the resident had a systolic blood pressure of 140 mm/Hg (millimeters of mercury) or more. A review of the May, June, and July 2023, Medication Administration Records revealed that staff administered the medication when the resident's systolic blood pressure was over the established parameter one time in May, four times in June, and two times in July. In an interview on July 28, 2023, at 12:50 p.m., the Director of Nursing confirmed the documentation indicated that Resident 5 received the midodrine hydrochloride when his systolic blood pressure was above 140 mm/Hg. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure pain management was consistent with professional standards and failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one of 19 sampled residents. (Resident 65) Findings include: Review of the facility policy entitled, Pain Assessment and Management Policy, reviewed November 9, 2022, revealed that the interdisciplinary care plan team would ensure that pain management and interventions were in place to address pain and the use of as needed pain medications would be based upon person-centered needs. Additional documentation provided by the facility indicated that a standardized 10-point numeric pain rating scale for cognitively impaired residents (0-3 mild pain, 4-6 moderate pain, and 7-10 severe pain) was to be used to determine level of pain. Clinical record review revealed that Resident 65 had diagnoses that included dementia, rheumatoid arthritis, osteoporosis, history of left femur fracture, and presence of artificial left hip joint. There were physician's orders dated February 11, 2023, for the resident to receive the narcotic pain medication morphine sulfate every four hours as needed for pain (failed to identify pain parameters) and acetaminophen every four hours as needed for mild pain. Review of Medication Administration Records revealed that the resident received the as needed narcotic (morphine sulfate) for mild pain on two occasions in June 2023, and once in July 2023. The resident did not receive any doses of as needed acetaminophen for mild pain in June and July, 2023. In addition, Resident 65's care plan directed that probable causes of pain were to be monitored, documented, and removed/limited where possible. There was a lack of documentation to support that non-pharmacological interventions were attempted to remove/limit pain prior to the administration of as needed pain medication on eight occasions in June 2023, and 10 occasions in July 2023. During an interview on July 28, 2023, the Director of Nursing confirmed that parameters had not been ordered for the administration of the narcotic pain medication and that there was a lack of documentation to support that non-pharmacological interventions for pain had been provided prior to the administration of as needed pain medication. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a PRN (as needed) psychoactive medication was limited to 14 days unless the physician documented in the clinical record the rationale for the PRN to be extended beyond 14 days for two of 19 sampled residents. (Residents 16, 73) Findings include: Clinical record review revealed that Resident 16 had diagnoses that included anxiety and post-traumatic stress disorder. On May 12, 2023, a physician ordered that staff administer a psychoactive medication (lorazepam) every six hours as needed for anxiety. The order for the lorazepam failed to include a time frame for the continued use of the medication. There was no physician documentation that it was appropriate for the order to be extended beyond 14 days. In an interview on July 28, 2023, the Director of Nursing confirmed that there was no evidence the physician documented a rationale for continuing the medication beyond 14 days. Clinical record review revealed that Resident 73 had diagnoses that included Alzheimer's dementia, aphasia (communication disorder), and anxiety. On July 10, 2023, a physician ordered that staff administer a psychoactive medication (lorazepam) four times a day as needed for anxiety. There was no physician documentation that it was appropriate for the order to be extended beyond 14 days. In an interview on July 28, 2023, at 10:33 a.m., the Director of Nursing confirmed that there was no evidence the physician documented a rationale for continuing the medication beyond 14 days. 28 Pa. code 211.12(d)(1)(5) Nursing services.

Based on observation and clinical record review, it was determined that the facility failed to re-evaluate the need for a physical restraint on an ongoing basis for one of 21 sampled residents. (Resident 3) Findings include: Clinical record review revealed that Resident 3 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set Assessment, dated September 7, 2021, revealed the resident had cognitive impairments, and required extensive assistance with transfers and limited assistance with locomotion (moving from place to place). Review of the current plan of care revealed the resident used a merri walker (a specialized enclosed walker that locks in the front) related to wandering and frequent falls. On September 14, 2021 between 10:44 a.m. and 12:55 p.m., and on September 15, 2021, between 9:47 a.m. and 12:10 p.m., the resident was observed in the merri walker with the front bar to the walker closed. There was no documented evidence that the interdisciplinary team had evaluated the ongoing use of the merri walker. 28. Pa Code 211.8(f) Use of restraints. 28. Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that safety interventions were in place for one of 11 sampled residents identified at risk for falls. (Resident 63) Findings include: Clinical record review revealed that Resident 63 was admitted to the facility with diagnoses that included [CONDITION(S)] and a history of falls. The ongoing and current care plan identified that the resident was at risk to fall because of [CONDITION(S)] drug use and a history of falling. On March 21, 2021, Resident 63 fell while being transferred to the bathroom by staff. Review of the fall committee note dated March 24, 2021, and the care plan revealed that staff was to have the resident use a bedside commode or provide a wheelchair transfer to the bathroom to prevent future falls. On May 12, 2021, and June 22, 2021, Resident 63 fell while being transferred to the bathroom. There was no documented evidence that staff offered the resident use of a bedside commode or a wheelchair transfer. In an interview on September 17, 2021, at 12:10 p.m., the Director of Nursing confirmed that there was no documented evidence staff offered Resident 63 a bedside commode or a wheelchair transfer to the bathroom on May 12, 2021, and June 22, 2021. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observation, clinical record review, staff interview, and facility policy review, it was determined that the facility failed to store respiratory equipment appropriately for one of one sampled residents receiving oxygen therapy. (Resident 39) Findings include: Review of the facility policy entitled, Oxygen Usage and Storage on Nursing Units, reviewed January 28, 2021, revealed that when oxygen tubing was not in use it should be kept in a plastic bag attached to the concentrator. Clinical record review revealed that Resident 39 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Assessment completed on July 19, 2021, revealed that the resident required extensive assistance of two staff for most activities of daily living. On November 9, 2019, the physician ordered that staff administer oxygen via nasal canula every evening and night shifts. Review of the Treatment Administration Records for September 2021, indicated that staff administered oxygen overnight to the resident. On September 14, 2021, at 10:41 a.m., and 12:34 p.m., September 15, 2021, at 12:46 p.m., and September 16, 2021, at 10:13 a.m., the oxygen nasal cannula tubing was not secured in the bag attached to the oxygen concentrator in accordance with facility policy. During an interview on September 17, 2021, at 9:50 a.m., the Director of Nursing confirmed that the oxygen tubing should have been secured in the attached bag. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to timely notify a resident's physician of an accident and change in condition that required physician intervention for one of 24 sampled residents. (Resident 59) Findings include: Clinical record review revealed that Resident 59 had [DIAGNOSES REDACTED]. On (MONTH) 10, (YEAR), at 7:15 a.m. a nurse documented that Resident 59 had fallen that morning at 12:50 a.m. According to the nurse's note, at 2:30 a.m., the resident complained of left leg/inner thigh pain and was medicated with [MEDICATION NAME] that provided some pain relief. The nurse also documented that the Registered Nurse (RN) had been notified. There was no evidence to support that the physican was notified of the resident's fall and increased pain at that time. It was not until that afternoon (12:04 p.m.) that the Registered Nurse Supervisor documented an assessment of the resident that showed that the resident continued with increased pain in the groin area and the physician was contacted regarding the resident's fall and change in condition. The physician ordered an X-ray of the resident's left hip that was completed at approximately 2:00 p.m. that afternoon and showed that the resident sustained [REDACTED]. In an interview on (MONTH) 2, (YEAR), at 11:25 a.m., RN1 (RN supervisor) stated that she did not notify the physician of Resident 59's fall and change in condition until mid day on (MONTH) 10, (YEAR). 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview it was determined the facility failed to ensure that adequate supervision was provided for one of 24 sampled residents. (Resident 291) Findings include: Review of the facility policy entitled Elopement (Preventative Protocols), dated (MONTH) 8, (YEAR), revealed that residents identified at risk for elopement or who have a history of wandering were to have elopement interventions implemented to ensure their safety. A resident with dementia who was actively seeking an exit or who wandered off their unit was to have an anti-elopement tag (Nevatec tag) applied to their arm or leg. The Nevatec tag was to be added to the nurse aide assignment sheet. The nursing assistant(s) assigned to the resident was to verify that the Nevatec tag was in place by signing the assignment sheet. Interview with the Director of Nursing on (MONTH) 2, (YEAR), at 10:00 a.m. revealed that when a resident wearing a Nevatec tag approached the doors of the nursing unit, the doors would lock and an alarm would sound if the resident got out the doors. Staff was to test the Nevatec tags weekly for batteries and function. Clinical record review revealed that Resident 291 was admitted to the facility on (MONTH) 8, (YEAR) and had [DIAGNOSES REDACTED]. Review of the nurses' notes revealed that a Nevatec tag was applied to the resident on (MONTH) 8, (YEAR). On (MONTH) 9, (YEAR), it was noted that the resident was to have distant supervision in his room and on the unit. On (MONTH) 10, (YEAR), the resident left the unit in the morning and was found standing outside the double doors to the unit. On (MONTH) 10, (YEAR) at 2:40 p.m., the resident was found outside of the nutrition services office outside of the unit and the alarm did not sound. There was no documented evidence that the resident's Nevatec tag was monitored on the nurse aide assignment sheet per facility policy. There was also no documented evidence that the tag's batteries and function were tested weekly. In an interview on (MONTH) 2, (YEAR), at 10:15 a.m. the Director of Nursing confirmed that there was no documented evidence that the Nevatec tag was monitored per policy and that it's function was tested weekly. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the pharmacist's recommendation was reviewed and acted upon for one of 24 sampled residents. (Resident 60) Findings include: Clinical record review revealed that the consultant pharmacist reviewed Resident 60's medication regimen on (MONTH) 19, (YEAR), and requested an evaluation and supporting [DIAGNOSES REDACTED]. There was no documentation in the clinical record that the physician had responded to and acted on pharmacist's recommendations. In an interview on (MONTH) 1, (YEAR), at 1:30 p.m., the Director of Nursing confirmed that the pharmacy recommendation had not been reviewed and acted upon by the physician. 28 Pa. Code 211.0(f)(3) Pharmacy services.

Based on clinical record review, staff and family interviews, and a review of facility investigative documentation, it was determined that the facility failed to maintain confidentiality of the clinical record and personal privacy for one of 18 sampled residents. (Resident R11) Findings include: Review of the facility Ethical Standards policy as published in the Employee Handbook (last reviewed October 2016), revealed that all staff were required to keep confidential any information concerning the facility. That included residents' medical information, except when sharing with authorized persons. Employees were also not permitted to photograph residents without permission. Clinical record review revealed that Resident R11 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. According to facility investigative documentation, on March 22, 2017, Nurse Aide (NA) 5 took a photograph of a note attached to Resident R11's clinical record. The note contained information about Resident R11's medical history that was not relevant to his care needs at the facility. Nurse Aide 5 shared this information with four other staff members (NA 6, Employee 3, NA 9, and NA 10). The facility investigative documentation further revealed that on March 24, 2017, NA 5 photographed Resident 11 and shared the photograph with two other people (NA 6 and Employee 3). In an interview conducted on April 6, 2017, at 1:00 p.m., Resident R11's spouse and responsible party confirmed that she did not give NA 5 permission to share medical information or photograph the resident. In an interview conducted on April 6, 2017, at 1:30 p.m., the Administrator confirmed that NA 5 shared medical information with unauthorized personnel and photographed the resident without permission. 28 Pa. Code 201.29(j) Resident rights.

Based on clinical record review and review of incident reports, it was determined that the facility failed to provide adequate supervision to prevent falls for one of three sampled residents. (Resident CR1) Findings include: Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An initial Minimum Data Set assessment dated [DATE], identified that the resident had memory impairment, that the resident needed one person assist to walk and that the resident had a history of [REDACTED]. The care plan from July 11, 2014, identified that the resident was at risk for falls related to vision/hearing problems, impaired cognition, vertigo and antidepressant use. Nurses' notes and incident reports identified that the resident had nine unwitnessed falls from July 11, 2014, to September 2, 2014. There was a lack of evidence to support that the facility had developed a specific plan to supervise the resident to prevent falls during this time period. On September 2, 2014, and September 3, 2014, the resident had additional unwitnessed falls. The interdisciplinary team reviewed these falls and added additional safety interventions to the care plan for staff to assist the resident out of bed and place at the nurses' station in view of staff by 7:30 a.m., and to provide frequent safety checks when the resident was in her room. There was no evidence to support how frequent the safety checks were being completed. The resident had five additional unwitnessed falls, including falls in her room, from September 3, 2014, through September 24, 2014. On January 21, 2015, at 8:00 a.m., staff heard a bed alarm and found Resident CR1 in her room on her knees next to the bed. Staff failed to have the resident out of bed and at the nurses' station at 7:30 a.m., for supervision to prevent falls in accordance with the care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, staff interview and policy review, it was determined that the facility failed to account for the disposal of a controlled medication for one of one sampled residents who received a Schedule II controlled substance. (Resident R22) Findings include: Review of the facility policy entitled "Disposition of Discontinued Medication" dated February 2013, revealed that controlled drugs were to be destroyed within the facility and witnessed by two registered nurse supervisors or a registered nurse and a licensed pharmacist. Clinical record review revealed that Resident R22 had a physician order from March 13, 2013, for staff to administer a Fentanyl patch (a Schedule II controlled substance used to treat pain) every three days. There was no documentation in the clinical record that two registered nurse supervisors or a registered nurse and a licensed pharmacist witnessed the destruction of Resident R22's Fentanyl patch at the time of final disposition. In an interview on April 3, 2013, at 1:00 p.m., LPN1 stated that she discards Fentanyl patches into the "Sharp" container and that no one else witnesses the disposal of the patch. 28 Pa. Code 211.8(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1) Nursing services.

Based on observation, staff interview and policy review, it was determined that the facility failed to provide a sink in one of two laundry areas for proper handwashing in accordance with infection control policies. ("Circle 2" nursing unit) Findings include: Review of the facility's infection control policy, dated March 4, 2011, revealed that staff was to wear personal protective equipment such as gloves, gowns and masks, when handling soiled items such as resident laundry. Upon removing personal protective equipment, staff was to immediately wash their hands with soap and water to prevent the spread of infection. During the environmental tour of the "Circle 2" nursing unit conducted on March 6, 2012, at 10:00 a.m., the laundry room was in use. Personal protective equipment was available for staff; however, there was no handwashing sink in this area. In an interview conducted on March 8, 2012, at 10:55 a.m., the Housekeeping Supervisor stated that the "Circle 2" laundry room was used by staff to clean resident clothing protectors and any item grossly soiled by any resident in the facility such as when they are ill. She further stated that staff used personal protective equipment because items washed in this laundry area have the high potential to be contaminated. She stated that after removing personal protective equipment, housekeeping staff leave the laundry area without washing their hands and wash their hands in another area of the nursing unit where the "kitchen station" is located.

Based on observation, review of the facility's environmental rounds documentation and staff interview, it was determined that the facility failed to ensure that a preventative maintenance program was maintained to ensure safe and comfortable water temperatures on three of five nursing units. (M1, M2, M2B) Findings include: During environmental tours of nursing units M1, M2, M2B on March 6, 2012, from 9:15 a.m., through 12:30 p.m., water temperatures in various resident's bathrooms and the unit bathing areas yielded high water temperatures that had the potential to be unsafe and uncomfortable for resident use. These water temperatures ranged from 112 degrees Fahrenheit to 122 degrees Fahrenheit. Review of the facility's preventative maintenance program revealed that hot water temperatures were to be monitored and recorded daily on the five nursing units. Temperatures were to be adjusted as needed. The facility was unable to provide documentation to support that staff had documented the results of the daily and weekly environmental rounds since June 24, 2011. In an interview on March 6, 2012, the Administrator stated that she was unaware that maintenance staff had not been documenting the results of the environmental rounds outlined in the facility's preventative maintenance program. 28 Pa. Code 205.63(c) Plumbing and piping systems required for existing and new construction. 28 Pa. Code 201.18(b)(e)(1)(3) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to provide the required Notice of Medicare Provider Non-coverage to three of three sampled residents whose Medicare coverage was discontinued. ( Residents CR1, CR2, CR3) Findings include: Clinical record review revealed that CR1 was admitted to the facility on [DATE], with Medicare coverage. The resident was discharged to home on February 17, 2012, with her Medicare coverage being discontinued. There was no documented evidence that the resident or responsible party was provided a Notice of Medicare Provider Non-coverage prior to discharge. Clinical record review revealed that CR2 was admitted to the facility on [DATE], with Medicare coverage. The resident was discharged to home on February 7, 2012, with her Medicare coverage being discontinued. There was no documented evidence that the resident or responsible party was provided a Notice of Medicare Provider Non-coverage prior to discharge. Clinical record review revealed that CR3 was admitted to the facility on [DATE], with Medicare coverage. The resident was discharged to home on February 13, 2012, with her Medicare coverage being discontinued. There was no documented evidence that the resident or responsible party was provided a Notice of Medicare Provider Non-coverage prior to discharge. In an interview on March 9, 2012, at 10:55 a.m., RN1 stated that she was unaware of the need and did not issue a Notice of Medicare Provider Non-coverage to the residents or their responsible party prior to discharge.