Every finding on record at Dresher Hill Health and Rehabilitation Center

Based on facility documentation and resident and staff interviews, it was determined the facility failed to ensure that essential equipment was in safe operating condition for one of two elevators. (elevator two)Findings include: Review of the facility documentation revealed that elevator two had malfunctioned on June 14, 2026, and on July 1, 5, and 21, 2026, and required a replacement part. In interviews on July 31, 2026, between 10:15 a.m. and 12:30 p.m., Resident 1 and Resident 2, and Employees 1, 2, 3, and 4 stated that they were aware that elevator two malfunctioned. In an interview on July 21, 2026, at 12:50 p.m., the Administrator confirmed the elevator malfunctioned and was in need of repair. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management.

Based on observation and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department and on two of four nursing units. (First floor, Second floor)Findings include: Observations during the tour of the dietary department on January 27, 2026, at 10:10 a.m., and January 29, 2026, at 9:35 a.m., revealed the following: In the dry storage area, there was a bottle of Realemon Juice with a best buy date of October 21, 2025. On the lower shelf of the cook's prep table, a container had lemon extract with a best by date of October 10, 2024, and a box of food dye with an expiration date of November 3, 2023. The container also had dirty measuring spoons. In the walk-in freezer there was a box of Harborbanks seafood shrimp that was open with no open date or expiration date and one box of gluten free breaded mini shrimp bags that was open with no open date or expiration date. The back splash of the griddle and stove had thick dry discolored splatter. The oven doors and knobs had dry thick discolored splatter. The shelf over the cooking surface was dusty. The flat griddle, that was confirmed not used for breakfast, had food debris and crumbs on the griddle and the front scrap disposal area. The stove top had charred debris crumbs and a white powdery dusty debris. The meat slicer table had crumbs and was sticky. There was debris and crumbs on the meat slicer. The top of the steamer was dusty. The steam table and prep table bottom shelf had crumbs, debris and a paper clip. The cook's prep table was dusty and had a dried slice of bread on the lower shelf. A wall shelf that contained the cooking spices had thick dust and debris. The lower shelf of the food prep table next to the dish area was dusty with dirt and debris. Observation of the first floor pantry January 27, 2026, at 1:53 p.m., revealed ice built up in the refrigerator freezer and the refrigerator floor had dried discolored staining and debris. In the microwave there was thick food splatter that contained crumbs and debris. During an interview on January 27, 2026, at 1:57 p.m., the Director of Nursing confirmed that the microwave is used to reheat resident food. Observation of the second floor pantry January 27, 2026, at 12:18 p.m., revealed ice built up in the refrigerator freezer and the refrigerator floor had dried liquid staining and debris. In the microwave there was food splatter that contained crumbs and debris. In an interview on January 27, 2026, at 12:23 p.m., a nurse aide (NA 3) confirmed that the microwave is used to reheat resident food. The ice scoop was observed on the dusty lower shelf of the rolling table for the ice cooler instead of being placed in the attached ice scoop pocket. In the cabinet below the sink there was a stained bath blanket. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on observation, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment on two of four nursing units. (1st floor low side, 2nd floor high side) Findings include: Observation throughout the facility January 27 through 29, 2026, from 10:00 a.m. to 2:45 p.m., revealed the following: A tube feeding pole in room [ROOM NUMBER] had a dried brown substance on it. There was a displaced floor tile in room [ROOM NUMBER] by bed 1. A mechanical lift (used to transfer residents from surface to surface) was observed with dirty wheels with knotted/intertwined thick [NAME] of hair and debris. A sit to stand lift (used to assist a resident to a standing position) was observed with dirty wheels with knotted/intertwined thick [NAME] of hair and debris and dirt and debris on the foot boards. The large shower chair back had a built up brown and pink substance on it. The shower room ceiling exhaust fan had heavy dust on it. A dried brown substance was observed on a tube feeding pole, bedside table, and privacy curtain in room [ROOM NUMBER]. Dust, debris, a hair ball and a dried brown substance were observed behind the oxygen concentrator and fall mat on the left side of the bed. The privacy curtain in room [ROOM NUMBER] was stained with a dark yellow substance and dust, crumbs and lint were observed on the left fall mat. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to implement enhanced barrier precautions and the use of personal protective equipment (PPE) to prevent the spread of infection for two of 22 sampled residents. (Residents 10 and 53)Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions, last reviewed June 2, 2025, revealed that enhanced barrier precautions were to be used with any high-risk resident with a wound or indwelling device during high contact care activities even when exposure to body fluids and blood is not anticipated, including during wound care, the care of feeding and tracheostomy tubes, providing hygiene, and changing briefs and linens. Standard precautions such as hand hygiene always apply and precautions include the use of protective gowns and gloves during high-risk activities. Clinical record review revealed that Resident 10 had diagnoses that included paraplegia and a pressure ulcer of the lower back region related to a recurrent abscess (an area under the skin where pus (infected fluid) collects). The Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 10 had a chronic left ischial (part of left hip bone) stage four pressure ulcer and was dependent on toileting and personal hygiene. On January 26, 2026, the wound nurse noted the reopening of the abscess. Observations on January 28, 2026, at 10:10 a.m. revealed a nurse aide (NA 2) entered Resident 10's room without wearing a protective gown prior to changing the resident's briefs. Clinical record review revealed that Resident 53 had diagnoses that included traumatic brain injury, quadriplegia, neurogenic bladder, and gastronomy status. Resident 53 required devices including a suprapubic catheter and an enteral feeding tube according to the MDS assessment dated [DATE]. Observations on January 28, 2026, at 10:00 a.m. revealed a physical therapist (PT 1) performed leg stretches on Resident 53 without wearing a protective gown. On January 29, 2026, at 1:00 p.m., the Director of Nursing confirmed that staff did not follow the facility infection control policy. 28 Pa. Code 211.10(d) Resident care policies. 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 provide adequate supervision to prevent a fall for one of nine sampled residents. (Resident 8)Findings include:Clinical record review revealed that Resident 8 had diagnoses that included dementia, end stage renal disease, and muscle weakness. Review of the Minimum Data Set assessment dated [DATE], indicated that Resident 8 was cognitively impaired and fully dependent on staff for assistance getting in and out of the shower and bathing. Review of Resident 8's care plan revealed that the resident had a problem with mobility and in his ability to perform activities of daily living such as bathing and required assistance with bathing. Review of facility documentation revealed that on January 8, 2026, at 4:00 p.m., Resident 8 was being assisted with a shower by a nurse aide (NA 1). During the shower, NA 1 left the shower room with no other staff present. During that time Resident 8 slipped out of the shower chair onto the floor. In an interview on January 29, 2026, at 1:34 p.m., the Director of Nursing and Administrator confirmed that a staff member should have been in the shower room throughout Resident 8's shower.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, pharmacy literature review, and staff interview, it was determined that the facility failed to ensure a resident's drug regimen was free from drugs used in an excessive dose for one of 21 sampled residents. (Resident 33) Findings include: Clinical record review revealed that Resident 33 was admitted to the facility on [DATE], and had diagnoses of a pressure ulcer and surgical incision site infection. A physician's order dated December 8, 2023, directed staff to administer 650 milligrams (mg) of a pain medication (acetaminophen) every four hours as needed for pain. A physician's order dated December 9, 2023, directed staff to administer 1,000 mg of the same pain medication (acetaminophen) every six hours for mild to moderate pain. A review of the medication packing information on the administration of acetaminophen revealed the maximum dose an adult should take in 24 hours should not exceed 4,000 mg. A review of the medication administration records revealed that Resident 33 received acetaminophen 1,000 mg four times and 650 mg one time, for a total of 4,650 mg within a 24-hour period on December 15 and 17, 2023. In an interview on January 5, 2024, at 10:10 a.m., the Director of Nursing confirmed that Resident 33 received over 4,000 mg of acetaminophen on December 15 and 17, 2023. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to administer medications in accordance with physician's orders for two of 22 sampled residents. (Residents 17, 56) Findings include: Review of the facility policy entitled, General Dose Preparation and Medication Administration, last reviewed December 28, 2022, revealed that facility staff should verify each time a medication was administered, that it was at the correct time, and that medications should be administered within timeframes. Clinical record review revealed Resident 17 was admitted to the facility on [DATE], with diagnoses that included heart failure and end-stage kidney disease. On December 8, 2022, the physician ordered midodrine hydrochloride three times a day to treat the resident's hypotension (low blood pressure). Staff was not to give the medication if the resident had a systolic blood pressure (the first number, the measurement of pressure in the arteries when the heart beats) of 110 millimeters of mercury (mm/Hg) or more. A review of the December 2022, and January 2023, Medication Administration Records (MARs), revealed that staff administered the medication when the resident's systolic blood pressure was over the established parameter 13 times in December, and 28 times in January. In an interview on January 27, 2023 at 11:05 a.m., the Director of Nursing confirmed that documentation indicated Resident 17 received the midodrine hydrochloride when the systolic blood pressure was above 110 mm/Hg. Clinical record review revealed Resident 56 was admitted to the facility on [DATE], with diagnoses that included psychosis, schizophrenia, and dementia. On December 2, 2022, the physician ordered divalproex sodium (an anticonvulsant medication) be given every eight hours at 6:00 a.m., 2:00 p.m., and 10:00 p.m. On December 14, 2022, the physician ordered quetiapine (an antipsychotic medication) be given to Resident 56 three times a day at 9:00 a.m., 1:00 p.m., and 5:00 p.m. Review of the MAR documentation for January 2023, revealed that the 1:00 p.m. dose of quetiapine and the 2:00 p.m. dose of divalproex Sodium were documented between 7:54 a.m. and 9:22 a.m. on January 1, 2, 4, 7, 9, 10, 12, 14, 15, 18, 19, 20, 23, 2023, outside of the administration time. Observations on January 26, 2023 at 10:02 a.m., revealed the 1:00 p.m. dose of quetiapine and the 2:00 p.m. dose of divalproex sodium were already signed out as refused for the day. In at interview on January 27, 2023 at 11:13 a.m., the Director of Nursing confirmed the medications were not administered within the ordered timeframes. CFR 483.25 Quality of Care Previously cited 02/18/2022. 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 monitor or provide behavioral interventions for the use of psychotropic medications for two of 22 sampled residents. (Residents 82, 86) Findings include: Review of the facility policy entitled, Psychoactive Medication Policy, last reviewed December 28, 2022, revealed that residents receiving psychoactive medication would have their behaviors and effectiveness of pharmacological and non-pharmacological interventions monitored and documented. On each shift, nurses were to document the number of behavior episodes, behavioral interventions, and any side-effects observed. Clinical record review revealed that Resident 82 was admitted to the facility on [DATE], and had diagnoses that included dementia with other behavioral disturbance, anxiety disorder, and depression. Review of physician's orders and Medication Administration Records (MARs) revealed that the resident received antidepressant medications (sertraline hydrochloride and trazodone hydrochloride) daily August 2 through December 9, 2022, anti-anxiety medication (Ativan) daily August 9 through December 9, 2022, and antipsychotic medications (olanzapine) daily August 9 through November 11, 2022 and (Seroquel) daily August 23 through December 9, 2022. There was no documentation to support that Resident 82 had been monitored for possible side-effects from the use of psychoactive medications August 2022, through November 17, 2022. During an interview on January 27, 2023, at 12:38 p.m., the Director of Nursing confirmed that side-effects had not been monitored for the use of psychoactive medications prior to November 17, 2022, for Resident 82. Clinical record review revealed that Resident 86 was admitted to the facility on [DATE], and had diagnoses that included schizophrenia, stroke, and aphasia (difficulty speaking). The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired. A physician's order dated December 29, 2022, directed staff to administer an anti-anxiety medication (lorazepam) as needed for anxiety. Review of the MAR revealed that staff administered the lorazepam on three occasions in December 2022, and 17 occasions in January 2023. There was no documentation to support that staff offered non-pharmacological interventions prior to the administration of the as needed psychoactive medication. In an interview on January 27, 2023 at 11:05 a.m., the Director of Nursing confirmed that there was no evidence of attempts to offer non-pharmacological interventions prior to administration of lorazepam. 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 Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's current status for one of 22 sampled residents. (Resident 60) Findings include: Clinical record review revealed that Resident 60 was admitted to the facility on [DATE], with diagnoses that included rheumatoid arthritis, pressure ulcers, and chronic pain. Review of the hospital discharge summary dated November 29, 2022, revealed that the resident had a history of upper and lower extremity contractures (a fixed tightening of muscles, tendons, ligaments, or skin which prevents normal movement). The MDS admission assessment dated [DATE], did not identify the resident as having upper and lower extremity impairment in functional range of motion on both sides under section G, Functional Status. In an interview on January 27, 2023, at 12:15 p.m., the Director of Nursing stated that the admission assessment did not identify the upper and lower extremity impairments and that the MDS was not coded to accurately reflect the resident's current status. CFR 483.20(g) Accuracy of Assessments. Previously cited 02/18/2022. 28 Pa. Code 211.5(f) Clinical records.

Based on clinical record review, observation, and resident interview, it was determined that the facility failed to ensure that a homelike environment was maintained for one of 22 sampled residents. (Resident 60) Findings include: Clinical record review revealed that Resident 60 had diagnoses that included rheumatoid arthritis, pressure ulcers, and chronic pain. Review of the Minimum Data Set assessment, dated December 7,2022, revealed Resident 60 had no cognitive impairment and required extensive assistance from staff with activities of daily living. On January 24, 2023, from 10:48 a.m. until 12:39 p.m., and on January 25, 2023, at 11:40 a.m., Resident 60's pillow was observed bloodstained. In an interview on January 24, 2023, at 10:48 a.m., Resident 60 stated he asked staff to change his pillow case but was told there were none available. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on facility policy review, clinical record review, staff interview, and resident interview, it was determined that the facility failed to permit each resident to remain in the facility unless the discharge was necessary, including the failure to provide documentation by the physician that the facility initiated discharge was justified for one of two sampled residents who were discharged from the facility. (Resident 1) Findings include: Review of the facility policy entitled, Discharge Planning Policy, dated November 5, 2021, revealed that requirements for involuntary discharge included documentation in the medical record by the resident's physician when discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan identified the resident was at risk for falls, chronic pain, had an activities of daily living/self-care deficit related to impaired mobility, an alteration in musculoskeletal status related to right above the knee amputation, and the need for supervised leaves of absence related to safety. On August 3, 2022, the social worker documented that a meeting was held with the resident, responsible party, and family to discuss the resident's 30 day discharge notice and that they stated that he was not ready to discharge. It was noted that the resident reported he would not leave until he received his prosthesis (artificial leg). It was also noted that the address/place for discharge on the notice was rescinded by the resident. Review of the document entitled, [NAME] Hill Health and Rehabilitation Center - SNF Discharge Notice, issued to Resident 1, revealed that the document was dated August 1, 2022, and indicated the resident would be discharged from the facility on August 31, 2022. It included that the reason for discharge was the resident's health had improved sufficiently so that he no longer needed the services of the facility. During an interview on August 4, 2022, at 1:55 p.m., Resident 1 stated that he was not able to discharge from the facility on August 31, 2022, due to his medical condition and no place to go. There was a lack of documentation to support that the resident's physician had determined that discharge was appropriate, including that the resident's health had improved sufficiently to no longer need services provided by the facility. In addition, there was a lack of documentation to support that the resident had established placement for a safe discharge. During an interview on August 4, 2022, the Administrator confirmed that Resident 1's physician had not determined that discharge from the facility was appropriate. 28 Pa. Code 201.25 Discharge policy. 28 Pa. Code 201.29(f)(g) Resident rights.

Based on clinical record review, staff interview, and resident interview, it was determined that the facility failed to provide services to enhance each resident's quality of life by offering showers as scheduled to four of six sampled residents. (Residents 1, 2, 3, CL1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included diabetes and difficulty walking. The Minimum Data Set assessment (MDS) dated [DATE], indicated that resident was alert and oriented and required limited assistance with bathing and personal hygiene. Review of Resident 1's current care plan revealed that she required staff to assist her with most activities of daily living. The resident was to receive a shower twice per week and as needed per resident request. During an interview on May 12, 2022, at 10:45 a.m., Resident 1 stated that she preferred to take a shower twice a week and was not offered the opportunity to do so. Review of Resident 1's shower record revealed that she had not been offered a shower nine of ten scheduled times during the 30-day period ending May 7, 2022. Clinical record review revealed that Resident 2 had diagnoses that included depression and muscle weakness. The MDS assessment dated [DATE], indicated that the resident was alert and oriented and required supervision for bathing and personal hygiene. The resident was to receive a shower twice per week. During an interview on May 12, 2022, at 11:25 a.m., Resident 2 stated that she preferred to take a shower twice a week and was not offered the opportunity to do so consistently. Review of Resident 2's shower record revealed that she had not been offered a shower eight of ten scheduled times during the 30-day period ending May 7, 2022. Clinical record review revealed Resident 3 had diagnosis that included dementia and muscle weakness. Review of the MDS assessment, dated February 14, 2022 revealed that the resident had cognitive impairments and required extensive assistance with personal hygeine. Review of Resident 3's current care plan revealed she had a self care performance deficit and was totally dependent on staff for shower or bathing. The resident was to receive a shower twice per week. Review of Resident 3's shower record revealed a lack of documentation to support that she was showered five out of 11 times since April 6, 2022. Clinical record review revealed that CL1 was admitted to the facility on [DATE], and had diagnoses that included diabetes, obesity, and muscle weakness. The MDS assessment dated [DATE], indicated that the resident was alert and oriented and was independent with all activities of daily living. The resident was to shower twice per week and as needed per resident request. There was a lack of documentation to support that CL1 was provided the opportunity to have a shower from April 4, 2022, to May 2, 2022. During an interview on May 12, 2022, at 3:50 p.m., the Nursing Home Administrator stated that he had no documentation to support that Residents 1, 2, 3, and CL 1 were provided showers. 28 Pa. Code 201.29(j) Resident rights. 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 ensure that staff implemented physician's orders for one of 24 sampled residents. (Resident 82) Findings include: Clinical record review revealed that Resident 82 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On December 15, 2021, a physician order directed staff to administer a medication ([MEDICATION(S)]) three times a day to treat the resident's [CONDITION(S)] (low blood pressure). Staff was not to give the medication if the resident had a systolic blood pressure (the first measurement of blood pressure when the heart beats, and the pressure is at it's highest) of 120 or more. A review of the January and February 2022, Medication Administration Records, revealed that staff administered the medication when the resident's systolic blood pressure was over the established parameter 28 times in January, and 11 times in February. During an interview on February 17, 2022, at 9:45 a.m., the Nursing Home Administrator confirmed that the documentation indicated that Resident 82 received the [MEDICATION(S)] when her systolic blood pressure was above 120. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, clinical record review and staff interview, it was determined that the facility failed to ensure that call bells were accessible for five of 24 sampled residents. (Resident 24, 33, 49, 50, 82) Findings include: Clinical record review revealed that Resident 24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment, dated November 29, 2021, reflected that the resident was able to communicate needs to staff and required extensive assistance from staff for mobility and activities of daily living such as toilet use, grooming, and hygiene. On February 15, 2022, at 10:40 a.m., the resident was observed in bed. The resident was heard asking for help and was unaware where his call bell was. The call bell was located on the floor out of the resident's reach. Clinical record review revealed that Resident 33 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment, dated November 20, 2021, reflected that the resident was able to communicate needs to staff and required extensive assistance from staff for mobility and activities of daily living such as toilet use, grooming, and hygiene. On February 15, 2022, at 11:27 a.m., and 1:12 p.m., and February 16, 2022, at 10:46 a.m., the resident was observed in a reclining chair watching television. The call bell was located draped over the corner end of the overbed light, out of the resident's reach . Clinical record review revealed that Resident 49 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment, dated January 21, 2022, reflected that the resident was able to communicate needs to staff and required assistance from staff for activities of daily living such as, toileting, grooming, and hygiene. On February 15, 2022, at 11:05 a.m., and 12:30 p.m., and February 16, 2022, at 10:00 a.m., the resident was observed in bed watching television. The call bell was located draped over the corner end of the overbed light, out of the resident's reach. Clinical record review revealed that Resident 50 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment, dated January 27, 2022, reflected that the resident was able to communicate needs to staff and required assistance from staff for activities of daily living such as toileting, grooming, and hygiene. On February 15, 2022, at 11:05 a.m., and 12:30 p.m., and February 16, 2022, at 10:00 a.m., the resident was observed in bed and the call bell was located on the floor under the head of the bed, out of the resident's reach. Clinical record review revealed that Resident 82 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment, dated December 23, 2021, reflected that the resident was able to communicate needs to staff and required extensive assistance from staff for mobility and activities of daily living such as toilet use, grooming, and hygiene. On February 16, 2022, at 10:22 a.m., the resident was observed laying in bed. The call bell was located on the floor under the bed, out of the resident's reach. 28 Pa. Code 211.12(d)(1) Nursing services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 3/2/21

Based on clinical record review and staff interview, it was determined that the facility failed to electronically transmit encoded complete Minimum Data Set (MDS) data to the Centers for Medicare & Medicaid Services (CMS) within 14 days after the facility completed the resident assessment for one of 24 sampled residents. (Resident 1) Findings include: Clinical record review revealed that there was a quarterly MDS assessment completed on January 24, 2022, for Resident 1; however, the record reflected that the MDS had not been exported until surveyor notification on February 16, 2022. The facility failed to electronically transmit encoded accurate and complete MDS data to the CMS system within 14 days after the quarterly assessment had been completed. In an interview on February 17, 2022, at 12:00 p.m., the Administrator stated that the MDS assessment had not been electronically transmitted in a timely manner. 28 Pa. Code 211.5(f) Clinical records.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's current status for two of 24 sampled residents. (Residents 84, 88) Findings include: Clinical record review revealed that Resident 84 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On July 23, 2021, a physician ordered for the resident to be administered an anti-coagulant medication ([MEDICATION(S)]) which was discontinued on December 16, 2021. Review of the MDS assessment dated [DATE], indicated that the resident had been administered an anti-coagulant medication in the last seven days. The MDS inaccurately reflected the use of an anti-coagulant medication, as the [MEDICATION(S)] had been discontinued on December 16, 2021. Clinical record review revealed that Resident 88 was admitted on [DATE]. Review of the admission MDS assessment dated [DATE], indicated that the resident had received insulin over the last seven days since admission. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the resident did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on February 17, 2022, at 12:00 p.m., the Administrator stated that the MDS assessments for the aforementioned residents had been inaccurately coded for the anti-coagulant medication and the insulin. 28 Pa. Code 211.5(f) Clinical records.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a care plan and interventions were developed for three of 24 sampled residents. (Residents 24, 33, 100) Findings include: Clinical record review revealed that Resident 24 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE], indicated that staff had administered anti-coagulant (a blood thinning medication) and an anti-depressant over the last seven days to the resident. Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no care plan developed to address the use of the anti-coagulant medication and the anti-depressant medication. Clinical record review revealed that Resident 33 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no care plan developed with interventions to address the use of the anti-psychotic and anti-depressant medication. Clinical record review revealed that Resident 100 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no care plan developed with interventions to address the use of the insulin medications. In an interview on February 17, 2022, at 11:45 a.m., the Nursing Home Administrator stated that the care plans had not been developed to address the use of the anti-coagulant medication, anti-psychotic medication, anti-depressant medications or insulin medication. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on policy review, clinical record review, observation, and interview it was determined that the facility failed to ensure that staff provided services consistent with professional standards of practice for two of two [CONDITION(S)] residents sampled. (Residents 22, 58) Findings include: Review of the facility policy entitled, Hemodialysis Care Policy, dated November 5, 2021, revealed that for residents who had a fistula or graft ( a graft or fistula is a vascular access point for a hemodialysis patient) staff was not to take a blood pressure on the arm where the fistula or graft was present. Clinical record review revealed that Resident 22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated November 18, 2020, relected that due to the resident's fistula/graft in the left upper arm, staff was not to take a blood pressure in that arm. Review of Resident 22's blood pressure summary revealed that from December 16, 2021, to February 16, 2022, nursing staff had taken the resident's blood pressure in her left arm 15 out of 36 times. In an interview conducted on February 17, 2022, at 10:22 a.m., the Director of Nursing confirmed that staff should have used the resident's right arm (and not the left) to check the blood pressure, in accordance with facility policy. Clinical record revealed that the Resident 58 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy entitled Hemodialysis Care Policy dated November 5,2021, a smooth clamp should be kept at the bedside of residents with a [CONDITION(S)] catheter in place. Review of the resident's current care plan initiated July 15, 2021, revealed an intervention for a smooth clamp to be at bedside in the event the permacath was cut or torn. Observation on February 15, 2022, at 11:33 a.m., revealed there was no smooth clamp available in the resident's room as noted on the care plan. In an interview on February 16, 2022, at 9:51 a.m., Resident 58 stated that he never saw a clamp at his bedside. In an interview on February 17, 2022, at 9:25 a.m., The Nursing Home Administrator confirmed that the facility failed to ensure the ready availability of necessary emergency supplies at the resident's bedside. 28 Pa. Code 211.12(c)(d)(1)(2) Nursing Services.

Based on clinical record review and observation, it was determined the facility failed to ensure that showers were provided to residents requiring assistance with grooming and personal hygiene for one of 24 sampled residents. (50) Findings include: Clinical record review revealed that Resident 50 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current care plan revealed that the resident had activities of daily living self-care deficits and required staff to offer a shower twice a week. During an interview on February 15, 2022, at 11:06 a.m., the resident stated that he did not know when he last had a shower and that he wanted one. The resident was observed to be disheveled. The resident's shower days were Monday and Thursday during day shift. Review of the clinical record revealed that the resident had not been offered bathing on eight occasions out of nine in the past 30 days. During an interview on February 17, 2022, at 9:45 a.m., the Nursing Home Administrator stated that he had no documentation to support that Resident 50 was offered a shower. 28 Pa. code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observations, and staff interview, it was determined that the facility failed to ensure that staff provided appropriate services to prevent further decrease in range of motion for one of two sampled residents with limited range of motion. (Resident 12) Findings include: Clinical record review revealed that Resident 12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], indicated the resident was unable to communicate and had functional limitation in range of motion of her arm and leg on one side of her body. The MDS also reflected that the resident required extensive assistance from staff for most activities of daily living. An Occupational Therapy discharge summary dated September 21, 2020, revealed that Resident 12 was to wear a right hand splint to minimize risk for contractures (a condition of shortening and hardening of muscles, tendons, or other tissue) to her hand. There was a care plan intervention for the resident to wear the right resting hand splint that staff was to apply during AM care and remove after PM care. Observations on February 15, 2022, at 1:40 p.m., and February 16, 2022, at 10:08 a.m., revealed the resident was in bed and was not wearing the right resting hand splint. In an interview on February 17, 2022, at 11:45 a.m., the Director of Rehabilitation confirmed that the resident needed the right resting hand splint and should have been wearing it during the day. CFR 483.25 (c) (2) Mobility Previously cited 3/2/21 28 Pa. Code 216.12 ) (d) (1) (5) Nursing Services

/18, 9/15/17 Based on clinical record review, review of facility incident investigation documentation, and review of select facility policy, it was determined that the facility failed to periodically monitor the skin of one of nine residents to timely identify a developing wound, that resulted in actual harm to the resident. By the time the wound was discovered, it was so severe that the resident had to have his right leg partially amputated. This deficiency is cited as past non-compliance (Resident 1). Findings include: Review of facility policy entitled, Bi-Weekly Skin Checks, dated (MONTH) 18, (YEAR), revealed that both nurse aides and licensed nurses were to periodically check the skin integrity of each resident. The policy reflected that nurses were to conduct bi-weekly skin checks, and that these were to be scheduled separately from skin checks that were to be done by the nurse aides twice a week with each shower given to the resident. The policy reflected that this will allow for each resident's skin to be observed at a minimum of four times each week. Clinical record review revealed that Resident 1 had been admitted to the facility on (MONTH) 3, (YEAR), and had [DIAGNOSES REDACTED]. of the legs and feet, to narrow, block, or spasm). A quarterly Minimum Data Set assessment (a periodic evaluation of resident care needs) dated (MONTH) 4, 2019, reflected that the resident required physical help for bathing. Clinical record review revealed that a nurse's note on (MONTH) 16, 2019 at 4 PM reflected that the nurse told Resident 1 that recent laboratory tests he had had indicated that he might have an infection, and so the physician had ordered a chest X-ray and a urine test to try to find the cause of the infection. The nurse's note reflected that Resident 1 told the nurse that he knew he had an infection. The note indicated that the resident then removed his right shoe and sock, revealing a wound on the entire top of his foot extending one to one and a half inches up the front of his leg. The nurse's note indicated thart the wound had slough and eschar (black, dead flesh) and that in two areas ligaments in the resident's foot were visible. The note reflected that the second, third and fourth toes of the foot were completely black and that the great toe had necrotic (black) area. The nurse's note indicated that the resident's right ankle and calf were swollen. The note indicated that the resident said his foot has been like this for approximately three weeks. A nurses' note about five hours later at 9:22 PM indicated that the resident told another staff that the wound had been present for a couple weeks. Clinical record review of documentation for the weeks prior to (MONTH) 16, 2019, revealed no evidence that staff had identified any impaired skin integrity of the Resident 1's right foot or leg. Further, documentation prior to (MONTH) 16, 2019, reflected that nurse aides and licensed nurses had documented that they had checked the resident's skin in accordance with facility policy and found no impaired skin integrity. Facility investigation of this incident revealed that prior to (MONTH) 16, 2019, staff had not monitored the resident's skin four times weekly in accordance with facility policy. For example: Employee 1, a licensed practical nurse, documented on (MONTH) 15, 2019 (one day before the wound was discovered), that she had performed a skin check that day on Resident 1 and found no skin issues. However, facility documentation of an interview with the adminsitrator on (MONTH) 16, 2019, reflected that Employee 1 did not say that she had checked the resident's feet and legs, but only the resident's arms and torso. Employee 2, a licensed practical nurse, documented that she had checked Resident 1's skin on (MONTH) 9, 2019, and found no skin issues. However, facility documentation of a telephone interview with the administrator on (MONTH) 17, 2019, reflected that Employee 2 admitted that she had not done the skin check, but had only asked Resident 1 if he had any skin issues. Clinical record documentation reflected that the resident was to have a shower every Monday and Thursday. (Based on the aforementioned skin checks policy, these scheduled shower days were also when nurse aides were to check the resident's skin.) Employee 3, a nurse aide, was Resident 1's assigned nurse aide on Monday (MONTH) 6, 2019 and Thursday (MONTH) 9, 2019. Nurse aide documentation reflected that Employee 3 showered the resident on (MONTH) 6, 2019, but not on (MONTH) 9, 2019. However in an interview with the administrator on (MONTH) 17, 2019, Employee 3 admitted that he had not showered the resident on either of those two days. Further, there was a lack of evidence to support that Employee 3 had checked the resident's skin on those days. In another instance, a nurse aide did not provide the resident with a shower (or check his skin) because the shower had not been listed on the nurse aide's assignment. Review of a facility policy entitled Resident Bath-Shower Schedule Policy, dated (MONTH) (YEAR), revealed that at the beginning of each shift, the charge nurse will make a copy of the resident bath-shower schedule and review the schedule for that day and shift with the nurse aides. The resident was due to have a shower on Monday (MONTH) 13, 2019, (three days before staff discovered the foot wound). Clinical record documentation revealed that staff had not showered the resident that day. Facility documentation reflected that in an interview with the adminsitrator on (MONTH) 17, 2019, Employee 6, the assigned nurse aide, said she did not shower Resident 1 because the shower was not listed on her assignment sheet. A review of Employee 6's assignment sheet for (MONTH) 13, 2019, revealed that there was no documentation that Resident 1 was to have a shower that day. In addition, there was a lack of evidence to support that the charge nurse ensured that the resident's scheduled showers were listed on nurse aide assignment sheets on other days as well. For example, Resident 1's scheduled showers were not listed on the nurse aide assignment sheets on (MONTH) 6, 2019, and (MONTH) 9, 2019. Based on these findings, there was a lack of evidence to support that staff monitored Resident 1's skin in accordance with facility policy. There was a lack of evidence that licensed nurses actually performed Resident 1's skin checks. There was a lack of evidence that the charge nurse ensured that the resident's scheduled showers were listed on the nurse aide assignment sheets. There was a lack of evidence to support that licensed nurses supervised nurse aides to ensure that scheduled showers (and skin checks ) were being done twice weekly in accordance with facility policy. Clinical record documentation revealed that the resident was transferred to the hospital on (MONTH) 16, 2019, and underwent a [MEDICAL CONDITION] of his right leg the next day. Facility documentation reflected that six days later on (MONTH) 23, 2019, the resident had to have a second surgery to revise the amputation from below his knee to above his knee. Information submitted by the facility to the Department included the following corrective actions in response to the injury incurred by Resident 1: [NAME] Resident 1 was transferred to the hospital for an evaluation on (MONTH) 16, 2019. B. Licensed nurses from the previous two weeks that completed the bi-weekly skin checks for Resident 1 were interviewed and addressed as needed. C. Certified Nursing Assistant's to provide showers for Resident 1 from the previous two weeks were interviewed and addressed as needed. D. A house-wide skin sweep was initiated on (MONTH) 16, 2019, and was completed on on (MONTH) 18, 2019. No other significant issues were identified. E. Reeducation of nursing staff was completed by the Staff Development Coordinator regarding resident refusals of showers and documentation. F. Licensed staff were re-educated regarding the completion of the head to toe skin assessment for bi-weekly skin checks and required documentation. G. Shower schedules were reviewed. Bi-weekly skin checks were reviewed. H. The Director of Nursing, or designees will complete five random body checks based on the bi-weekly skin checks will occur for four weeks, three random body checks will occur for four weeks, and two random body checks based on the bi-weekly skin checks will occur for four weeks. I. Unit Managers will complete shower documentation review for refusals and follow-up documentation five times per week for four weeks, five random shower documentation will be reviewed for refusals and follow-up documentation weekly for two months. [NAME] Social Service Director, or designees will interview five residents a week regarding the completion of the bi-weekly skin check and showers five times a week for four weeks, three times a week for four weeks, and two times a week for four weeks. K. The results of the audits will be submitted to the facility QAPI committee for further review and recommendations with a compliance date of (MONTH) 17, 2019. The information submitted by the facility to the Department indicated a completion date of (MONTH) 17, 2019, and reflected that the facility substantiated the allegation of neglect of Resident 1 by Employees 1, 2 and 3. This deficiency is cited as past non-compliance. 28 Pa. Code 201.18(b)(1) Management Previously cited 10/19/18, 9/15/17 28 Pa. Code 211.10(d) Resident care policies Previously cited 10/19/18, 9/15/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 10/19