Every finding on record at Dock Terrace

Based on clinical record review and staff interview, it was determined that the facility failed to provide restorative nursing services to increase or prevent a reduction in range of motion (ROM) for one of two sampled residents with limitations in ROM. (Resident 25) Findings include: Clinical record review revealed that Resident 25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE], revealed that Resident 25 had a limitation in range of motion to both sides of her lower extremities (hip, knee, ankle, foot). Record review of a physical therapy discharge summary dated June 16, 2021, revealed recommendations for a restorative nursing program (RNP) that included passive ROM and transfers to maintain current level of performance and prevent decline. There was no documented evidence that a RNP was implemented per the therapy discharge recommendations. In an interview on November 4, 2021, at 11:58 a.m., the Director of Nursing confirmed a RNP was not implemented for Resident 25 per the therapy discharge recommendations. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of the dietary manual, clinical record review, observation, and staff interview, it was determined that the facility failed to provide food prepared in a form designed to meet individual needs for three of ten sampled residents who were on a mechanically altered diet. (Residents 5, 31, 60) Findings include: Review of the facility diet manual for modified menus, dated September 3, 2021, revealed that hot dogs should be in chopped form when served to residents ordered a mechanically altered diet that included chopped meats and that beef roast should be in chopped form when served to residents ordered a mechanically altered diet that included chopped meats. Clinical record review revealed that Resident 31 had diagnoses that included dysphagia (difficulty eating or swallowing). On June 1, 2020, the physician ordered for the resident to have a mechanically altered diet that included ground meats. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had some memory impairment, required supervision for eating, and that he received a mechanically altered diet. On November 2, 2021, during a lunch meal observation at 12:05 p.m., Resident 31 was sitting at a table in the dining room and he was observed being served and eating a hamburger. The hamburger was served as a patty, not chopped into small pieces or ground. In an interview on November 3, 2021, at 12:19 p.m., Dietary Aide 1 (DA 1) confirmed that Resident 31 was served a hamburger as a patty during the lunch meal on November 2, 2021. In a subsequent interview on November 4, 2021, at 9:39 a.m., the Director of Nursing (DON) confirmed that hamburger meat served to residents on a ground meat diet should be served in ground texture. Clinical record review revealed that Resident 60 had diagnoses that included [CONDITION(S)], history of a stroke, slurred speech and [CONDITION(S)] (difficulty speaking). On August 6, 2020, a physician ordered for the resident to have a mechanically altered diet that included chopped meats. The MDS assessment dated [DATE], indicated that the resident had some memory impairment, required supervision for eating and that she received a mechanically altered diet. Review of a nutritional assessment dated [DATE], revealed that the resident chose to eat in her room and that she received a mechanically altered diet that included chopped meats. Observation on November 2, 2021, at 12:15 p.m., revealed that the resident was seated in her wheelchair in her room in front of her bedside table. Staff had served her lunch which included a whole hot dog on a bun. The hot dog was not chopped. The resident then ate the hot dog. In an interview on November 4, 2021, at 9:44 a.m., the DON stated that the resident was to receive chopped meats as ordered by the physician. Clinical record review revealed that Resident 5 had diagnoses that included dysphagia. On November 2, 2020, the physician ordered for the resident to have a mechanically altered diet that included chopped meats. The MDS assessment dated [DATE], indicated that the resident had some memory impairment, required supervision for eating, and that she received a mechanically altered diet. On November 3, 2021, during a lunch meal observation at 12:03 p.m., Resident 5 was observed sitting at a table in the dining room, she was observed being served and eating beef roast. The beef roast was not chopped. In an interview during this observation period, DA 1 confirmed Resident 5 should have received chopped beef roast, she was not served beef roast in the correct form.

Based on review of facility policy and observation, it was determined that the facility failed to store food under sanitary conditions on one of three nursing units. (Ivy Lane) Findings include: Review of the facility policy titled, Use and Storage of Resident Obtained Foods-HC, dated June 25, 2021, revealed that when a resident chose to consume food at the facility that was not obtained by the facility, safe and sanitary use, storage, and handling shall be maintained as follows: foods requiring refrigeration would be labeled with the residents name, dated, and placed in a designated refrigerator or freezer. Unconsumed foods would be disposed of as follows or upon evidence of spoilage: leftover food discarded after three days. Frozen items would be discarded after 30 days. The dietary department would monitor this. Observation of the nourishment refrigerator on the Ivy Lane nursing unit on November 4, 2021, at 9:58 a.m., revealed a container of lemon flavored yogurt product with a facility label that was dated September 12, 2021, and a manufacturer expiration date of October 5, 2021, a container of blueberry yogurt product with a manufacturer expiration date of September 22, 2021. There was a container of a food product with a date of October 28, 2021, a container of a food product that was dated October 24, 2021, a Whole Foods grocery store bag with a date of October 30, 2021, a bottle of a red Powerade drink that was not labeled with a resident name or dated. Observation of the freezer revealed a container of salted caramel [MEDICATION(S)] ice cream product with a date of September 22, 2021, and a Rita's container of an orange frozen product that was not labeled or dated. CFR 483.60 Food Procurement Store/Prepare/Serve-Sanitary Previously cited 11/25/2020 28 Pa. Code 201.18(b)(3) Management.

Based on observation and review of facility documentation, it was determined that the facility failed to serve and store food under sanitary conditions in the kitchen and one of three healthcare unit kitchens. (Ivy Lane) Findings include: Observation of the kitchen on November 23, 2020, at 9:15 a.m., revealed a tray of prepared sloppy joe (hamburger meat in sauce) with a use by date of November 18, 2020, a tray of prepared beef with a use by date of November 18, 2020, a tray of stuffed pork chop with a use by date of November 22, 2020, and a tray of prepared shrimp with no label or use by date in the walk in refrigerator. Review of food temperature logs revealed no documented evidence that food temperatures were obtained or recorded for the breakfast and lunch meals on November 4, 2020, the breakfast meal on November 18, 2020, and the dinner meal on November 19, 2020. Observation of the Ivy Lane dining area on November 23, 2020, at 11:30 a.m., revealed an uncovered container of thickening powder on a table with a small plastic cup in the powder. A thick, brown substance was observed on the bottom of the container's lid. Review of food temperature logs in the dining area revealed no documented evidence that food temperatures were obtained or recorded for the breakfast meal on November 1, 2020, the lunch meal on November 7, 2020, and the breakfast and lunch meals on the following dates in November of 2020: 6th, 14th, 20th. 28 Pa. Code 201.18(b)(3) Management.

Based on observations during the initial and daily environmental tours, it was determined that the facility failed to ensure that the resident's environment was free of accident hazards on two of three nursing units. (Ivy Lane, Willow View) Findings include: Observations during the initial tour of the Ivy Lane unit, conducted on (MONTH) 9, 2019, from 10:20 a.m. to 2:10 p.m., and a subsequent tour on (MONTH) 10, 2019, from 9:23 a.m. to 12:35 p.m., revealed an unsecured medication cart in the hallway that had four pair of scissors that were easily accessible. There were eight cognitively impaired, mobile residents that had access to these potentially harmful items. Observations during the initial tour of the Willow View unit, conducted on (MONTH) 9, 2019, from 9:30 a.m. to 11:10 a.m., and a subsequent tour on (MONTH) 10, 2019, from 10:00 a.m. to 12:10 p.m., revealed an unsecured medication cart with one pair of scissors that was easily accessible. There were 10 cognitively impaired, mobile resdient's that had access to the potentially harmful item. 28 Pa. Code 201.18(b)(1) Management.

Based on observation, clinical record review and staff interview, it was determined that the facility failed to provide appropriate services to prevent further decrease in range of motion for one of three sampled residents with limited range of motion. (Resident 59) Findings include: Clinical record review revealed that Resident 59 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated (MONTH) 19, 2019, indicated that the resident was severely cognitively impaired, had functional limitation in range of motion, and required extensive assistance from staff for most activities of daily living. The ongoing care plan dated (MONTH) 3, (YEAR), revealed that the resident had self-performance deficits and that staff would provide a blue palmar (hand) cone to the right hand to prevent further contractures. On (MONTH) 18, (YEAR), Resident 59 was ordered to wear a blue hand cone on her right hand at all times for contractures. Review of an occupational therapy discharge summary dated (MONTH) 19, 2019, was for staff to provide a right hand roll to decrease the risk of contractures. Observations on (MONTH) 9, 2019, from 10:06 a.m. to 2:30 p.m. and (MONTH) 10, 2019, from 9:10 a.m. to 1:15 p.m., revealed that the resident was out of bed without the recommended right hand device applied. In an interview on (MONTH) 11, 2019, at 12:50 p.m., the Director of Nursing stated that the facility did not provide appropriate services for a resident with functional limitations. 28 Pa. Code 211.12(d)(1) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 6/8/18

Based on observation, it was determined that the facility failed to ensure that supplements were stored under sanitary conditions for one of three units. (Ivy Lane) Findings include: Review of the facility policy entitled Nourishment's, Resident Specific Snacks and Med Pass Program dated (MONTH) (YEAR), revealed that the nutritional supplements were to be supplied to nursing for distribution with the medication pass. Nursing was responsible for dating the product when opened and to clearly identify the use by date. All opened product was to be discarded after 48 hours. Review of manufacturer's specifications on the label of the nutritional supplement revealed that the product was to be discarded four days after being opened. Observation on (MONTH) 9, 2019, at 2:01 PM revealed a container of nutritional supplement on the medication cart on Ivy Lane that was labeled as being opened on (MONTH) 4, 2019 with a use by date of (MONTH) 8, 2019. The product was in use of (MONTH) 9, 2019. 28 Pa. Code 211.6(f) Dietary services

Based on clinical record review, observation, review of facility policy and staff interview, it was determined that the facility failed to ensure that the interdisciplinary team assessed resident's capabilities to self administer medications for one of one sampled residents who self administered medications. (Resident 61) Findings include: Review of the policy entitled, Self Administration of Medications, dated (MONTH) 15, (YEAR), indicated that if a resident desired to self administer medications an assessment was to be conducted by the interdisciplinary team to determine if the practice would be safe for the resident. Observation on (MONTH) 6, (YEAR), at 12:27 p.m., revealed that Resident 61 was seated in her room in her wheelchair and she had a tube of pain relieving cream (Aspercream) on her bedside table. Resident 61 stated she was able to self administer the Aspercream and that it did help to alleviate the pain especially in her hands. The tube of Aspercream was empty and the resident stated that she needed to request a new one from the nursing staff. Clinical record review revealed that the resident had [DIAGNOSES REDACTED]. There was a current physician's orders [REDACTED]. The order also included that the resident was able to keep the cream at her bedside. Review of the current plan of care revealed a problem area of pain in her wrists and hands and an intervention was to keep the Aspercream at bedside for self-administration. Review of the Medication Administration Record [REDACTED]. There was no documented evidence that the interdisciplinary team completed an assessment for self-administration prior to the use of the Aspercream as per facility policy. In addition, there was no documentation to support that staff monitored the use of the Aspercream on the Medication Administration Record. In an interview on (MONTH) 8, (YEAR), at 9:29 a.m., the Director of Nursing stated that the interdisciplinary team had failed to complete the assessment for the resident to safely self-administer the Aspercream and to keep the medication at her bedside. In addition, she stated that the facility failed to document use of the Aspercream on the Medication Administration Record. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the pharmacist failed to identify and report a drug irregularity for two of eight sampled residents who were on anti-psychotic medications. (Residents 28, 63) Findings include: Clinical record review revealed that Resident 28 had [DIAGNOSES REDACTED]. Review of the current physician's orders [REDACTED]. There was no documented evidence that the pharmacist reported the drug irregularity that required an assessment for a possible gradual dose reduction during the monthly pharmacy reviews. Clinical record review revealed that Resident 63 had [DIAGNOSES REDACTED]. Review of the current physician's orders [REDACTED]. There was no documented evidence that the pharmacist reported the drug irregularity that required an assesment for a possible gradual dose reduction during the monthly pharmacy reviews. In an interview on (MONTH) 8, (YEAR), at 9:38 a.m., the Director of Nursing stated that there was no documented evidence that the pharmacist had identified the drug irregularity for a possible gradual dose reduction of an anti-psychotic for the two aforementioned residents since the medication was originally ordered by the physician. 28 Pa. Code 211.9(a) Pharmacy services. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to ensure drugs and biologicals were stored under proper temperature controls for one of two medication storage areas. (The dementia unit medication storage room) Findings include: Review of the medication storage policy dated (MONTH) 15, (YEAR), revealed that the facility was to maintain a temperature log in the storage area to record temperatures at least once a day. Review of the medication refrigerator temperature log revealed that temperatures were documented monthly on the dementia unit. There was no documented evidence that the medication refrigerator temperature log was completed daily. Observation of the medication refrigerator on (MONTH) 6, (YEAR) at 9:47 a.m., revealed that it contained [MEDICATION NAME] and [MEDICATION NAME] insulin. The vial of [MEDICATION NAME]and the vial of [MEDICATION NAME]were to be stored between 36 degrees and 46 degrees Fahrenheit per the instructions of the manufacturer. Due to the lack of documentation of daily temperature recordings there was no way to determine if these medications were being stored within the parameters established by the manufacturer. In an interview on (MONTH) 6, (YEAR), at 11:20 a.m., the Director of Nursing stated that the medication refrigerator temperature log was to be documented daily in the medication storage area. 28 Pa. Code 211.9(a) Pharmacy services.

Based on observation, policy review, and facility documentation review it was determined that the facility failed to store medications subject to potential abuse in separately locked, permanently affixed compartments on three of three nursing units. Findings include: Review of the facility policy entitled controlled substance storage (dated November 2015) revealed that schedule II-V medications and other medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separate from all other medications . During observation of the medication pass on the Willow View nursing unit on June 22, 2016, at 9:10 a.m., a Schedule IV controlled substance (lorazepam) was stored in the drawer of the medication cart with other non-controlled medications. Further observations of the other two medication carts (Ivy Lane, Country Cottage) revealed that the lorazepam was not stored in a separately locked compartment in accordance with facility policy. According to the order listing report, there were 14 residents in the facility who received lorazepam. 28 Pa. Code 211.12(d)(1) Nursing services.

Based on observation, it was determined that the facility failed to ensure that sanitary conditions were provided during meal service on one of three nursing units. (Ivy Lane). Findings include: During observation of lunch on June 21, 2016, at 11:50 a.m., through 12:30 p.m., in the Ivy Lane dining room, Dietary Employee 1 (DE1) applied gloves and was serving residents plated food. Throughout the meal period, DE1 cleared soiled dishes and garbage, and touched her body numerous times, while serving the residents their meals and assisting them with their drinks. DE1 did not wash her hands and change her gloves in between tasks. 28 Pa. Code 211.6(f) Dietary services

Based on review of the facility's "Criminal Record Checks Policy," review of personnel records and staff interview, it was determined that the facility failed to obtain a criminal record check for one of five sampled employees. (Employee 1) Findings include: A review of the facility's "Criminal Record Checks Policy," dated November 1, 2013, revealed that a 'Criminal Record Check" was to be completed for all persons who were offered employment. " Review of Employee 1's personnel file revealed that he was hired on April 29, 2014, and that as of August 1, 2014, a criminal record check had not been completed. In an interview on August 1, 2014, at 11:05 a.m., the Senior Human Resource Campus Manager and Benefits Coordinator stated that Employee 1' s "criminal background check was missed." 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.19 Personnel policies and procedures.

Based on observation of the medication rooms, it was determined that the facility failed to ensure that all drugs with the potential for abuse (controlled substances) were secured in a locked, permanently affixed compartment at all times in two of two medication rooms. (Country Cottage and Ivy Lane/Willow View) Findings include: Observation on July 29, 2013, at 12:00 p.m., revealed that the refrigerator inside the Country Cottage unit medication room contained two plastic bags with a total of 22 syringes of a Schedule IV medication (Ativan gel). The medications were not in a separate locked, permanently affixed compartment. Observation on July 29, 2013, at 11:30 a.m., revealed that the refrigerator inside the medication room for the Ivy Lane/Willow View unit contained a box of emergency medications including one vial of a Schedule IV Medication (Ativan). The box was not permanently affixed to the refrigerator. 28 Pa. Code 211.12(d)(1) Nursing Services.

Based on observation during the environmental tour of the food service department and one of three nursing units (Country Cottage) and staff interview, it was determined that the facility failed to store juice and nutritional supplements according to manufacturer's specifications. Findings include: Observation during the environmental tour of the food service department on July 29, 2013, at 11:48 a.m., revealed undated thawed cartons of nutritional supplements (juice drinks and milk shakes) stored in the reach-in refrigerator. Additional observation on July 30, 2013, at 8:30 a.m., on the Country Cottage nursing unit revealed undated opened containers of juices and an undated thawed carton of a nutritional supplement in the dining area refrigerator. Review of manufacturer's specifications on the product labels of the nutritional supplements revealed that the products were to be discarded 14 days after being thawed. During an interview on July 31, 2013, at 9:10 a.m., the Assistant Director of Dining Services confirmed that containers of juice and nutritional supplements were to be labeled with an "opened" date and "use by" date.

Based on policy review and staff interview, it was determined that the facility failed to revise infection control policies and procedures to reflect current practice utilized by the facility. Findings include: Review of the facility's "Infection Control" policy manual revealed it was updated on December 12, 2012. Review of the facility's "Contact Precautions" policy revealed that staff was to implement additional protective measures when deemed needed by facility staff to prevent the spread of infection. Those measures included the use of gowns and gloves when direct contact with either the resident or resident's environment was expected. Review of the facility "Methicillin Resistant Staphylococcus Aureus (MRSA)" policy revealed that staff was to use "contact precautions" when caring for any resident "infected or colonized" with the MRSA organism (colonization is when the organism is present, however there are no signs of infection). In an interview conducted on July 31, 2013, at 9:00 a.m., the facility infection control nurse stated that staff no longer needed to use gowns unless the resident had an active infection. She stated that residents that were colonized were given individualized precautions based on the resident's symptoms. She stated that the policy was not updated during the last review to reflect current practice. 28 Pa. Code 211.10(b) Resident care policies. Previously cited 6/22/12

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that clinical record documentation was complete and accurate for one of 15 sampled residents. (Resident R18) Findings include: Clinical record review revealed that Resident R18 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. On July 1, 2011, a physician ordered TEDS (compression stockings to prevent blood clots). Observations on June 20, 2012, at 10:35 a.m., and 2:04 p.m., and June 21, 2012, at 12:20 p.m., and 1:15 p.m., revealed that the resident was not wearing her compression stockings. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In an interview on June 21, 2012, at 1:30 p.m., RN 1 (Care Coordinator) could not find the stockings in the resident's room. In addition, an interview on June 22, 2012, at 8:15 a.m., revealed that RN1 found three pairs of the stockings in the resident's laundry. 28 Pa. Code 211.5(f) Clinical records.

Based on observation, it was determined that the facility failed to ensure that personal privacy was maintained for two of 17 sampled residents. (Residents R37, R51) Findings include: On July 13, 2011, at 8:36 a.m., Resident R37 was observed receiving wound care in her room. At the time of the observation, the resident's privacy curtain was not used and the door to the resident's room was open. The resident was visible from the hallway. On July 14, 2011, at 9:10 a.m., Resident R51 was observed receiving wound care in her room. At the time of the observation, the resident's privacy curtain was not used and the door to the resident's room was open. The resident was visible from the hallway. 28 Pa. Code 201.29(j) Resident rights.

Based on observation, staff interview and policy review, it was determined that the facility failed to ensure that aseptic technique was followed during wound care for two of 17 sampled residents. (Residents R37, R51) Findings include: Review of the facility's policy "Aseptic Treatments and Dressing Changes" (dated June 8, 2011) revealed that nursing staff was to set up a clean field on a water resistant pad. Staff were also to place soiled dressings in a plastic bag. In an interview conducted July 14, 2011, at 10:45 a.m., the Director of Nursing stated that nursing staff were to clean equipment used during dressing changes, such as scissors, before and after each use. On July 13, 2011, at 8:26 a.m., RN1 was observed performing a dressing change to Resident R37's left heel wound. During the procedure, the nurse did not establish a clean field, and placed her supplies directly on the floor. The nurse used scissors to trim a piece of non-adherent dressing that was then placed directly on the resident's wound. The nurse failed to clean the scissors before or after cutting the dressing. On July 14, 2011, at 9:10 a.m., RN2 was observed performing a dressing change to Resident R51's right foot wound. During the procedure, the nurse used scissors to trim a piece of non-adherent dressing that was then placed directly on the resident's wound. The nurse failed to clean the scissors before or after cutting the dressing. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services.