Every finding on record at Country Meadows Nursing Center of Bethlehem

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of eight sampled residents. (Resident 4)Findings include:Clinical record review revealed that Resident 4 was admitted to the facility on [DATE], and had diagnoses that included retention of urine. Review of the Minimum Data Set assessment dated [DATE], indicated that the resident was alert and was frequently incontinent of urine. The Care Area Assessment summary dated May 23, 2026, noted that the resident's urinary incontinence was to be addressed in the care plan. There was no evidence that interventions to address Resident's 4's urinary incontinence were included in the care plan.In an interview on August 5, 2026, at 8:37 a.m., the Administrator confirmed there was no documented evidence that the identified care area was addressed in the care plan.28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on facility policy review, staff and resident interviews, clinical record review, and review of electronic call bell logs, it was determined that the facility failed to answer call bells in a timely manner to provide care and services respectful of each resident's dignity and preferences to promote the quality of life for two of eight sampled residents. (Residents 54 and 58)Findings include:Review of the facility policy entitled Call Lights: Accessibility and Timely Response, dated April 15, 2026, revealed that staff were responsible for responding to a call light in a reasonable amount of time. Clinical record review revealed that Resident 54 had diagnoses that included acute post-hemorrhagic anemia (inability of healthy red blood cells to carry oxygen to the tissues and organs due to losing a large amount of blood very quickly). A physician's progress note, dated July 30, 2026, indicated that the resident was alert and oriented and required assistance from staff for activities of daily living such as, transfers, personal hygiene, and toileting. Review of the care plan revealed that Resident 54 was at risk for injury due to falls related to a decline in function from lack of movement). The interventions included that staff encourage the resident to use the call bell for assistance. In an interview on August 5, 2026, at 10:30 a.m., Resident 54 stated that staff took a long time to answer call bells which had affected his ability to receive care and services in a timely manner. Clinical record review revealed that Resident 58 had diagnoses that included fracture of the right femur, presence of right artificial joint, and muscle weakness. The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and required assistance from staff for activities of daily living, such as toileting and dressing. Review of the care plan revealed that Resident 58 was at risk for falls due to impaired mobility and a right hip fracture. The interventions included that staff encourage the resident to use the call bell for assistance. In an interview with Resident 58 on August 4, 2026, at 2:00 p.m., Resident 58 stated that she sometimes had to wait over 30 minutes for staff to answer call bells which had affected her ability to receive care and services in a timely manner Review of the facility form entitled, [NAME]-CARE Report, for Resident 54 revealed that from July 27, 2026, through August 5, 2026, there were six occurrences when the call bell response time was from 22 to 60 minutes. From July 21, 2026, through August 5, 2026, for Resident 58, there were 12 occurrences when the call bell response time was from 22 to 43 minutes.During interviews on August 5, 2026, at 8:46 a.m. and 10:45 a.m., the Administrator confirmed the expected call bell response time was 15 minutes and that the previously mentioned residents waited more than the expected response time of 15 minutes. CFR 483.10(a)(1) Residents RightsPreviously cited 7/31/25.28 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 and the resident's responsible party or the legal representative with a written notice of transfer that included all required information, including a statement of the resident's appeal rights and the Ombudsman information in writing upon discharge from the facility for two of eight sampled residents. Additionally, it was determined that the facility failed to provide copies of written discharge or transfer notices to a representative of the Office of the State Long Term Care Ombudsman for two of eight sampled residents who were transferred out of the facility. (Residents 2 and 4) Findings include: Clinical record review revealed that Resident 2 was discharged to the hospital on March 24 and March 29, 2026, after changes in condition. There was no documented evidence that the resident and resident's responsible party, or the legal representative, were provided information regarding appeal rights and State Long-Term Care Ombudsman information or that the facility provided copies of the written transfer notices to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 4 was discharged to the hospital on June 5, 2026, after a change in condition. There was no documented evidence that the resident and resident's responsible party, or the legal representative, were provided information regarding appeal rights and State Long-Term Care Ombudsman information, or that the facility provided copies of the written transfer notices to a representative of the Office of the State Long-Term Care Ombudsman. In an interview on August 5, 2026, at 8:40 a.m., the Administrator confirmed that the transfer notice did not include the required information and notification of discharge was not provided to a representative of the Office of the State Long-Term Care Ombudsman. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(2) Management. 28 Pa. Code 201.29(a)(c.3)(2) Resident rights.

Based on policy review, staff and resident interviews, clinical record review, and review of electronic call bell logs, it was determined that the facility failed to answer call bells in a timely manner to provide care and services respectful of each resident's dignity and preferences to promote the quality of life for three of 17 sampled residents. (Residents 1, 25, and 28)Findings include: Review of the facility's policy entitled Call Lights: Accessibility and Timely Response,” dated April 29, 2025, revealed that staff were responsible for responding to a call light in a reasonable amount of time. In an interview on July 31, 2025, at 8:45 a.m., the Nursing Center Operations Manager confirmed the expected call bell response time was within 15 minutes. Clinical record review revealed that Resident 1 had diagnoses that included pneumonia, muscle weakness, and difficulty walking. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was able to communicate his needs to staff and required assistance from staff for activities of daily living, such as toileting and dressing. Review of the care plan revealed that Resident 1 had physical limitations and was at risk for falls. The interventions included that staff ensure the call bell was within reach and encourage use of the call bell for assistance. In an interview on July 29, 2025, at 1:05 p.m., Resident 1 stated that staff took a long time to answer call bells which had affected his ability to receive care and services in a timely manner. Clinical record review revealed that Resident 25 had diagnoses that included cerebral infarction (stroke), hemiplegia and hemiparesis affecting left non-dominant side, and urinary tract infection. The MDS assessment dated [DATE], indicated that the resident was able to communicate his needs to staff and required assistance from staff for activities of daily living, such as toileting and dressing. Review of the care plan revealed that Resident 25 had physical limitations and was at risk for falls. The interventions included that staff encourage the use of the call bell for assistance. In an interview with Resident 25 on July 29, 2025, at 10:00 a.m., Resident 25 stated that he sometimes had to wait over an hour for staff to answer his call bells which had affected his ability to receive care and services in a timely manner. Clinical record review revealed that Resident 28 had diagnoses that included congestive heart failure, muscle weakness, and chronic kidney disease. The MDS assessment dated [DATE], indicated that the resident was able to communicate her needs to staff and was dependent on staff assistance for all activities of daily living such as toileting and dressing. Review of the care plan revealed that Resident 28 had physical limitations and was at risk for falls. The intervention included that staff ensure the call bell was within reach and encourage use of the call bell for assistance. In an interview on July 20, 2025, at 11:24 a.m., Resident 28 stated that staff took a long time to answer call bells which had affected her ability to receive care and services in a timely manner. Review of the facility form entitled, [NAME]-CARE Report, for Residents 1, 25, and 28, revealed that from July 15 through July 21, 2025, and July 24 through July 29, 2025, there were 16 occurrences when the call bell response time exceeded 15 minutes, and the call bell response time was between 19 to 91 minutes. During an interview on July 31, 2025, at 10:45 a.m., the Nursing Center Operations Manager confirmed the previously mentioned residents waited more than the expected response time of 15 minutes. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to develop and implement a comprehensive care plan that addressed each resident's needs as identified in the comprehensive assessment for two of 17 sampled residents. (Residents 5, 25) Findings include: Clinical record review revealed that Resident 5 had diagnoses that included dementia, major depression disorder, and chronic kidney disease. The Minimum Data Set (MDS) assessment dated [DATE], noted that the resident had severely impaired cognition, had impaired communication abilities, was frequently incontinent of urine and required substantial assistance with toileting hygiene. The MDS Care Area Assessment (CAA) summary dated June 28, 2025, noted that the resident’s communication and urinary incontinence were to be addressed in the care plan. There was no documented evidence that interventions to address Resident 5’s communication or urinary incontinence were addressed in the current care plan. Clinical record review revealed that Resident 25 had diagnoses that included cerebral infarction (stroke), hemiplegia and hemiparesis affecting left non-dominant side, and urinary tract infection. The MDS assessment dated [DATE], noted that the resident had urinary incontinence. The MDS CAA summary dated May 23, 2025, noted that the resident’s urinary incontinence was to be addressed in the care plan. There was no documented evidence that interventions to address Resident 25’s urinary incontinence were included in the current care plan. In an interview on July 31, 2025, at 8:43 a.m., the Nursing Center Operations Manager confirmed the identified care areas were not addressed in the care plans. 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 implement physician's orders for two of 17 sampled residents. (Residents 7 and 25)Findings include: Review of the policy entitled Elimination Bowel Protocol, last reviewed April 29, 2025, revealed that the day shift (7:00 a.m. to 3:00 p.m.) and evening shift (3:00 p.m. to 11:00 p.m.) and medication nurses will check the bowel movement documentation in the electronic medical record (EMR). If no bowel movement had occurred in the past three days, the day shift medication nurse was to administer prune juice to the resident. If no bowel movement had occurred by the evening shift after administration of the prune juice, the evening shift medication nurse was to administer 30 milliliters (ml) of Milk of Magnesia as ordered by the physician. If no bowel movement had occurred by the next day on the evening shift, then the medication nurse was to administer a Dulcolax suppository as ordered by the physician. If the resident had no bowel movement by the next morning, the medication nurse would contact the physician for further orders. Clinical record review revealed that Resident 7 had diagnoses that included Parkinson's disease and age-related osteoporosis (weak bones). The physician's orders dated February 8, 2025, directed the staff to administer Milk of Magnesia and a suppository for constipation as needed. Review of the care plan revealed Resident 7 had the potential for constipation and instructed the facility to follow bowel protocol for bowel management. Review of facility documentation revealed that Resident 7 did not have a bowel movement (BM) July 3 through 7, 2025. There was no documented evidence that staff administered Milk of Magnesia on the third day without a BM, July 6, 2025, per the facility policy. Resident 7 did not have a BM July 13 through July 15, 2025. Resident 7 received Milk of Magnesia on July 16, 2025, which was ineffective. On July 17, 2025, Resident 7 received another dose of Milk of Magnesia and no suppository. In an interview on July 31, 2025, at 1:40 p.m., the Director of Nursing confirmed that Milk of Magnesia should have been given on July 6, 2025, per the bowel protocol and a suppository should have been given on July 17, 2025.Review of the facility policy entitled Medication Ordering and Receiving from Pharmacy, last reviewed on April 29, 2025, revealed that the nurse was not to take a medication from the emergency box (e-box) without checking allergies on the medical record and possible drug interactions with the pharmacist.Clinical record review revealed that Resident 25 had diagnoses that included cerebral infarction (stroke), essential hypertension, and heart disease. On May 19, 2025, the physician noted that Resident 25 had an allergy to metoprolol (a medication for high blood pressure). Review of the resident's medication administration records for May and July of 2025, revealed an allergy to metoprolol. Review of care plan revealed an allergy to Metoprolol. On June 30, 2025, staff noted that Resident 25 was experiencing tachycardia (rapid heart rate). The physician ordered staff to administer metoprolol which was to be obtained from the e-box. Clinical record review revealed that Registered Nurse (RN) 1 administered metoprolol. There was no evidence that RN 1 verified the resident's allergies upon pulling the medication from the e-box or prior to administration. After the medication was administered, RN 1 noted Resident 25's allergy to metoprolol and the resident was sent to the hospital for evaluation.In an interview on July 30, 2025, at 1:05 p.m., the DON confirmed that the nurse did not contact the pharmacy prior to retrieving the Metoprolol from the e-box and failed to determine if Resident 25 had an allergy to Metoprolol by checking the medical record as directed by facility policy.28 Pa. Code Resident Care Policies (a)(d)28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, and resident and staff interview, it was determined that the facility failed to schedule care to accomodate resident preferences for one of 16 sampled residents. (Resident 93) Findings include: Clinical record review revealed that Resident 93 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], indicated that the resident had slight memory impairment, felt that it was very important to choose her own clothes and to choose her own bed time and required extensive assistance with most activities of daily living. Review of the care plan identifed the resident had a elf care deficit due to [CONDITION(S)] and falls. There was an intervention for the resident to be out of bed to her wheelchair with the assist of one staff person for transfers. Review of a nursing admission note dated August 8, 2022, revealed that the resident was alert and oriented and able to make her needs known. Review of a written internal communication to staff dated August 18, 2022, revealed that R93 was on the Get up list for 11:00 p.m., to 7:00 a.m., shift and that she was to be washed and dressed by the end of the shift. On August 18, 2022, at 10:07 a.m, a nurse noted that the resident was tearful and crying and was upset that staff did not get her out of bed earlier and insistent that everyone forgot about her. The note further indicated that the staff was to attempt to get the resident out of bed early in the a.m., per resident preferences. On September 3, 2022, at 8:48 a.m., a nurse noted that the resident had been tearful and crying this a.m., upset that staff did not get her out of bed earlier. In an interview on September 7, 2022, at 1:23 p.m., Resident 93 stated that it was her normal routine to get up by 7:00 a.m., and receive care; however, there had been a few times that staff did not get her up early as per her preference. In an interview on September 8, 2022, at 9:24 a.m., the Director of Nursing stated that as per the internal communication form to staff members, it had been decided that the resident was to get up and receive care from staff on the 11:00 p.m., to 7:00 a.m., shift as per the resident's preference. 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.12(d)(3) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a Minimum Data Set (MDS) assessment accurately reflected the status of one of 16 sampled residents. (Resident 43) Findings include: Clinical record review revealed that Resident 43 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE], revealed that section A 2100 (identification information) inaccurately indicated that the resident was discharged to an acute hospital setting. In an interview on September 8, 2022, at 9:26 a.m., the Director of Nursing stated that the aforementioned MDS assessment had been inaccurately coded that the resident was discharged to a hospital as opposed to discharged to the community which was defined as private home/apartment, board/care, assisted living or group home.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement interventions to prevent contractures for one of two sampled residents with limited range of motion. (Resident 39) Findings include: Clinical record review revealed that Resident 39 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], indicated that the resident was nonverbal and totally dependent on staff for dressing. Review of an occupational therapy discharge summary dated January 13, 2022, revealed a right palm guard was recommended to increase safety and to reduce the risk of further medical complication. On January 13, 2022, a physician ordered that staff apply a right palm guard with morning care. Observations on September 7, 2022, from 10:09 a.m. through 1:31 p.m. revealed that the resident was out of bed to her wheelchair with no palm guard observed in place. Observations on September 8, 2022, from 9:00 a.m. through 10:15 a.m. revealed that the resident was out of bed with no palm guard observed in place. In an interview on September 8, 2022, at 11:20 a.m., the Director of Nursing stated that Resident 39's right palm guard was to be in place and had not been in place as ordered by the physician and as recommended by occupational therapy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that safety interventions were implemented for one of four residents sampled. (Resident R1) Findings include: Clinical record review revealed that resident R1 had diagnoses that included [CONDITION(S)] and muscle weakness. On November 24, 2021, a physician directed staff to provide the assist of two staff members with all transfers of the resident from chair to bed. A note by a nurse on December 7, 2021, at 7:25 p.m., revealed that one staff member assited the resident with a transfer back to bed following toileting . Upon sitting on the bed, a large amount of blood was noted coming from a laceration on the resident's right lower extremity. In an inteview on December 13, 2021, at 10:10 a.m., the Director of Nursing confirmed that the facility failed to ensure that two staff assited the resident with a transfer as ordered by the physician. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on facility policy review, clinical record review and staff interview, it was determined that the facility failed to thoroughly investigate injuries of unknown origin for one of 12 sampled residents. (Resident 6) Findings include: Review of the facility policy entitled, Accidents and Incidents - Investigating and Recording, dated February 2021, revealed that nursing staff must conduct an immediate investigation of an accident or incident, including injuries of unknown origin. All accidents or incidents involving residents must be thoroughly documented in the resident's record and an incident report completed, including a description of the action taken and a description of the preventative measures implemented to prevent such accident/incident from recurring. Clinical record review revealed that Resident 6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment, dated July 7, 2021, revealed the resident had memory impairment and required extensive assistance from staff with activities of daily living. A skin assessment completed on August 28, 2021, revealed the resident had a purple bruise located on the left forearm. Another skin assessment completed on September 1, 2021, revealed a purple bruise on her left hand. There was no evidence that the facility completed a thorough investigation into the cause of both injuries. In an interview on September 30, 2021, at 10:05 a.m., the Director of Nursing confirmed there was no documentation to support that the facility thoroughly investigated the cause of both injuries of unknown origin for Resident 6. 28 Pa. Code 211.10(d) Resident care policies. 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 attempt non-pharmacological interventions prior to the administration of as needed pain medication for one of 12 sampled residents. (Resident 21) Findings include: Clinical record review revealed that Resident 21 was admitted to the facility on [DATE], and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the August 2021, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on September 30, 2021, at 10:05 a.m., the Director of Nursing confirmed that there was no documentation to support that non-pharmacological interventions were attempted prior to the administration of the as needed pain medication. 28 Pa. Code 211.12(d)(1) Nursing services.

Based on clinical record review and observation, it was determined that the facility failed to implement physician's orders and recommendations from a wound consultant for one of 19 sampled residents. (Resident 26) Findings include: Clinical record review revealed that Resident 26 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated (MONTH) 17, 2019, indicated that the resident had memory impairment and required extensive assistance with Activities of Daily living including dressing. Review of a physician's note dated (MONTH) 10, 2019, revealed that the resident was recently hospitalized with right lower extremity [MEDICAL CONDITION] and a right ankle abscess, Achilles tenectomy with full thickness skin grafting. On (MONTH) 8, 2019, a physician ordered for staff to apply Prevalon boots (off-loading device) to the right foot when out of bed. Review of a wound consult dated (MONTH) 19, 2019, revealed that recommendations for treatment of [REDACTED]. The off loading device (Prevalon boot) was recommended to be kept on at all times to off load and float the heel and wound. Observations on (MONTH) 21, 2019, at 11:54 a.m., and again on (MONTH) 22, 2019, at 10:46 a.m., revealed that the resident was out of bed, dressed and in his wheelchair without the Prevalon boot in place on his right foot as ordered by the physician and recommended by the wound consultant. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, policy review and staff interview, it was determined that the facility failed to incorporate the residents choice to not be resuscitated into the treatment plan and did not obtain physician orders that were consistent with the residents documented wishes in the event of [MEDICAL CONDITION] for one of 15 sampled residents. (Resident R54) Findings include: Review of the facility policy DNR/Code Status Policy dated February 2016, revealed that the resident was to be asked by a social services representative whether or not they would want CPR performed in the event of [MEDICAL CONDITION] and if DNR (do not resuscitate) was chosen then social services was to fax the DNR form to the physician for signature and the signed DNR form would be placed on the clinical record. Clinical record review revealed that Resident R54 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of hospital records revealed Resident R54 had a do not resuscitate order in the hospital and review of Resident R54's advance directive on the clinical record revealed the residents wishes were to not be resuscitated in the event of [MEDICAL CONDITION]. Review of a social service note in the clinical record dated February 10, 2017, revealed that the resident is DNR. There was no evidence that the attending physician was sent a DNR form to complete per facility policy and there was no physician order indicating the resident's choice to not be resuscitated in the event of [MEDICAL CONDITION]. In fact, the clinical record had a sticker on the front of the record indicating the resident was a full code status(indicating that staff was to perform CPR in the event of [MEDICAL CONDITION]). The resident remained a full code from admission through review on February 17, 2017 despite her documented wishes for a DNR. In an interview on February 16, 2017, at 2:00 p.m. the NHA confirmed that Resident R54's request for DNR status had not been followed through per policy and that the sticker on the clinical record indicating the resident was a full code was not reflective of the resident's choice for no code status. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(a) Resident rights. Previously cited [DATE]

Based on facility policy review, clinical record review, facility documentation, staff interview, and observation it was determined that the facility failed to thoroughly investigate an accident for one of 15 sampled residents (Resident R26). Additionally, the facility failed to ensure that the resident environment was free of accident hazards on the nursing unit. Findings include: Review of the facility policy entitled Accidents and Incidents-Investigating and Recording dated February 2016, revealed that a written incident/accident report was to be completed for each occurrence involving residents. All incidents regardless of severity were to be reported to the Administrator and Director of Nursing and an investigation was to be completed. Clinical record review revealed that Resident R26 had [DIAGNOSES REDACTED]. On October 17, 2016, the resident received a foley catheter (a urinary drainage system). Review of nursing notes revealed that the resident self propelled in his wheelchair. Review of the clinical record and facility documentation from October 9, 2016 to November 17, 2016, revealed that the resident was frequently agitated and attempted to pull out his foley catheter several times. Nursing notes revealed that on November 17, 2016, the resident took a pair of scissors from the medication cart and cut his urinary drainage system. There was no incident report or investigation into this incident. In an interview on February 17, 2017, at 8:55 a.m. the Nursing Home Administrator confirmed that an incident report and investigation were not completed and should have been completed for the incident. Observations on February 15, 2017, from 8:30 a.m. to 3:00 p.m. revealed scissors on top of the medication cart left unattended throughout the day. In an interview on February 17, 2017, at 8:55 a.m. the Nursing Home Administrator stated that there were six cognitively impaired, mobile residents on the nursing unit. 483.25(h)Free of Accident Hazards/Supervision/Devices Previously cited 3/11/16, 2/26/15 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 3/11/16, 2/26/15

Based on observation, it was determined that the facility failed to ensure that sanitary conditions were provided in the dietary department. Findings include: Observation on March 8, 2016, at 8:20 a.m., in the dietary department revealed that Dietary Employee 1 had been preparing a hydration cart that included lemons. Dietary Employee 2 had hair that was not contained in a hair net. During the environmental tour of the dietary department on March 8, 2016, at 8:30 a.m., there was food debris on the bottom of Refrigerator A. There was also food debris on the bottom shelf of a table in the salad preparation area. Clean plates and bowls were stored on the bottom shelf of this table. Observation of the freezer revealed an opened bag of hot dogs that was not re-sealed with a date. There was a bag of frozen raisin bread dough that was not labeled.

Based on observation, clinical record review, policy review and staff interview, it was determined that the facility failed to follow its infection control policy in regard to isolation , handwashing, wound care, medication administration, equipment cleaning and storage of respiratory equipment for seven of 15 sampled residents, and for two of six residents observed during the medication pass. ( Resident R4, R19, R15, R21, R32, R34, R53, R59, R60) Findings include: Review of the infection control policy, dated November 2015, regarding contact and airborne precautions revealed that the facility was to provide personal protective equipment (PPE) in each room for residents needing those precautions for use upon entering the isolation rooms. Additionally, the policy indicated that signs were to be posted to alert all employees, residents, volunteers and visitors to the necessary infection control measures. Any resident requiring airborne isolation was to have the door to the room closed at all times. Additionally, signs were to be placed inside of the front cover of the resident's chart indicating that all staff and visitors wear gloves and gown when entering the rooms. Review of the facility policy Handwashing revealed that staff was to wash their hands whenever gloves were taken off. Handwashing consisted of vigorously washing the hands for 15 seconds, drying hands with a clean paper towel and turning off the water with the paper towel. Review of the facility policy Eye Instillation revealed that staff was to wash hands before and after giving medications into a resident's eye. Review of the facility policy entitled Equipment changing and cleaning, revealed all residents with equipment such as an oxygen face masks were to have a bag for the equipment to be placed in to when not in use. Review of the facility policy entitled Application of Superficial Moist Heat dated February 2015, revealed that the [MEDICATION NAME] (hot pack) machine should be maintained according to manufacturer guidelines. The [MEDICATION NAME] user manual stipulated that the unit was to be drained and cleaned at least every two weeks. Clinical record review revealed that Resident R4, R19, R34 and R59 all had physicians' orders for contact precautions. Observation from March 8 through March 11, 2016, revealed no posted signs or PPE available for use in these rooms. In an interview on March 11, 2016 at 10:35 a.m., the Administrator and LPN2 ( Infection Control Nurse) confirmed that there was no signage in place to notify visitors of the precautions and no PPE available when visitors entered the resident's room. Clinical record review revealed that Resident R21 had a physician's order to be on airborne precautions. Observation from March 8 through March 11, 2016, revealed no signage on the door to the room. Observation on March 9, 2016, from 11:05 a.m. to 11:25 a.m. revealed that the door to room was open. In an interview on March 11, 2016, at 10:35 a.m., the Administrator and LPN2 confirmed that there was no sign in place to notify visitors of precautions to be taken and no PPE available when visitors entered the resident's room. Observation of medication pass for Resident R60 on March 9, 2016, at 08:30 a.m., revealed LPN1 did not wash her hands for 15 seconds, touched the faucet with her bare wet hand instead of using a towel and failed to wash her hands before and after eye drop instillation per policy. Observation of medication pass for Resident R32 on March 9, 2016, at 08:38 a.m., revealed that LPN3 did not wash her hands thoroughly before beginning an eye drop instillation as per the facility policy. In addition, LPN3 failed to wash her hands for 15 seconds after removing her gloves. Initial tour of the C Hall on March 8, 2016 at 08:30 a.m., revealed an uncovered oxygen mask in Resident R53's room. Observation on March 9. 2016 at 1:16 p.m., of a wound dressing change for Resident R15 by LPN4 revealed the nurse failed to wash her hands after removing her gloves on two occasions during the procedure. Observation on March 9, 2016 at 2:00 p.m., of a wound dressing change for Resident R59 by LPN1 revealed the nurse failed to wash her hands for at a minimum of fifteen seconds, failed to wash hand between two different wound sites and failed to turn off faucet with a paper towel. In addition LPN1 failed to maintain a clean working field by placing the garbage bag on the clean field and then proceeded to use the garbage bag throughout the treatment observation. Review of the [MEDICATION NAME] maintenance and cleaning records on March 11, 2016, at 08:30 a.m. revealed that there was no evidence that the [MEDICATION NAME] was cleaned in November and December 2015, January 2016 and cleaned only once on February 10, 2016. In an interview on March 11, 2016, at 08:45 a.m., the Director of Rehabilitation Services confirmed that the unit was not cleaned in November and December 2015 and only once in February 2016.

Based on clinical record review, review of incident reports and observation, it was determined that the facility failed to ensure that assessed safety devices were in place in order to prevent accidents for two of 15 sampled residents. (Residents R17, R19) In addition, the facility failed to ensure that the environment was free of accident hazards on one of three hallways on the nursing unit. (C hall) Findings include: Clinical record review revealed that Resident R17 had [DIAGNOSES REDACTED]. The Minimum Data (MDS) assessment dated [DATE], indicated that the resident had memory impairment and had a history of [REDACTED]. The corrective action on the incident report was for staff to place mats at the resident's bedside. Review of the current care plan identified the resident's risk for falls and the directed staff to place bi-lateral floor mats on the floor when the resident was in bed. In addition, the care plan identified that the resident had a self-care deficit due to a history of a stroke and seizure disorder. The intervention since December 7, 2015, was for staff to ensure that the two padded half siderails were in the upright position to enable the resident to turn and reposition. Observation on March 8, 2016, at 12:22 p.m., 1:30 p.m., and 2:06 p.m., revealed the resident was in bed and the siderails were not padded and the bi-lateral floor mats were not in place. Clinical record review revealed that Resident R19 had [DIAGNOSES REDACTED]. Review of the current care plan revealed that the resident was at risk for skin alteration and directed staff to apply protective sleeves (geri-sleeves) to the resident's upper extremities for protection from skin tears. Observation on March 8, 2016, from 12:21 p.m., through 2:00 p.m., revealed Resident R19 was dressed and in her wheelchair without the protective sleeves in place. In addition, review of incident reports for Resident R19 revealed that on December 10, 2015, a nurse aide discovered a bruise on the resident's right upper shin. On January 11, 2016, a skin tear was discovered on the resident's left upper shin and again on January 22, 2016, during care, a nurse aide discovered a skin tear on the resident's left calf. Further review of the incident reports revealed that the facility failed to document or recommend corrective action for the injuries in order to prevent future occurrences of skin tears. Observation of C Hall, on March 9, 2016 at 2:15 p.m. and March 10, 2016 at 1:15 p.m., revealed multiple items on both sides of the hallway creating cluttered hallways and blocked access to the handrails between resident rooms 27, 28, 29, 30 and 31. Items included clean linen cart, bedside table, arm chair, rolling chair, garbage can, dirty linen hampers, transfer lifts, medication cart and treatment cart. 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 2/26/15 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 2/26/15 28 Pa. Code 211.10(d) Resident Care policies

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a Notice of Provider Non-Coverage and Appeals Rights letter was provided to one of three sampled residents. (Resident CR1) Findings include: Clinical record review revealed that Resident's CR1 last day to qualify for skilled coverage under Medicare was February 9, 2016. The facility was to present the Notice of Medicare Provider Non-Coverage, to the resident or the residents' Power of Attorney (POA), at least two days prior to the last day of coverage, so that if the resident or POA wished to appeal the decision, they would have time to do so. Resident CR1's POA signed the Medicare Non-Coverage letter on February 14, 2016. In an interview on March 11, 2016, at 11:00 a.m., the Administrator stated that the letter was sent certified mail with a received signature by the POA on February 9, 2016 which was the date of the services were terminated and not 48 hours prior to termination of services. 28 Pa. Code 201.18(e)(1) Management.

Based on observation and record review, it was determined that the facility failed to provide care and services in a manner and in an environment that enhanced each resident's dignity for one of 12 sampled residents. (Residents R48) Findings include: Clinical record review revealed that Resident R48 had [DIAGNOSES REDACTED]. On April 15, 2016 at 9:30 a.m., 10:00 a.m., 11:05 a.m., 12:25 p.m., and 1:10 p.m., the resident was observed wearing two different colored slipper socks (no shoes) and her abdomen was exposed. At 9:30 a.m. and 10:00 a.m., the resident was observed in an activity program with eight other residents. At 11:05 a.m., the resident was participating in a religious activity with 32 other residents. At 12:25 p.m. and 1:10 p.m., the resident was eating lunch in the dining room with 27 other residents. At no time during the observation period did staff attempt to cover the resident's abdomen or provide matching socks. 28 Pa. Code 201.29(j) Resident rights.