Every finding on record at Elk Haven Nursing Home

Based on review of facility policies, observations, and staff interviews it was determined that the facility failed to appropriately discard outdated medications for one of three medication rooms reviewed (B Wing medication room ). Findings include: Review of facility policy entitled Storage of Medications dated 1/27/26, revealed The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals; All such drugs shall be returned to the dispensing pharmacy or destroyed. Review of manufacturer's guidelines revealed that an open vial of Aplisol (a solution used for tuberculosis testing upon admission and employment) should be discarded within 30 days after opening. Observation of drug storage on 5/27/26, at 9:55 a.m. of the B Wing medication room revealed an opened vial of Aplisol with an open date of 4/10/26. During an interview on 5/27/26, at the time of observation, Registered Nurse (RN) Employee E1 confirmed that the open vial of Aplisol had an open date of 4/10/26. RN Employee E1 also confirmed that the vial of Aplisol should have been discarded. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing service

Based on review of a facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of three resident pantries reviewed (B Wing). Findings include: A facility policy entitled Food Storage- Unit Pantries/Activity Kitchens dated 1/27/26, indicated that dining services will stock the unit refrigerators with supplements and snacks and discard outdated items as necessary; bulk milk, juices, drinks, and supplements shall be dated when opened and discarded after four days of date opened; and non-perishable items shall be discarded per the use by date on the label provided that they are properly sealed, stored within the correct temperatures, and show no signs of deterioration. A facility policy entitled Nutritional Supplements dated 1/27/26, indicated that nutritional supplements need to be kept at refrigerated temperature of (34-40 degrees Fahrenheit) once opened; if kept at this temperature range, product is good for four days from the time opened. Review of the Med Pass supplement label revealed After open, consume product within 4 (four) days if properly refrigerated. Observation on 5/26/26, at 2:20 p.m. in the B wing pantry refrigerator revealed an opened Med Pass supplement dated opened 5/20/26, one cardboard container of thickened water dated opened 5/24/26, with a use by date of 5/21/26, and one cardboard container of thickened water dated opened 5/25/26, with a use by date of 5/21/26. During an interview at that time Licensed Practical Nurse Employee E2 confirmed that the opened Med Pass was outdated and should have been discarded on 5/24/26 (two days past), and the outdated containers of thickened water should have been discarded on 5/21/26, (five days past). 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible, and exercise reasonable care for the protection of the resident's property from loss. Findings include: A facility policy entitled, Resident Property-Missing/Damaged dated 1/27/26, indicated that the facility shall be responsible for ensuring the safety and security of all resident personal belongings. Observation on 5/28/26, at 9:48 a.m. of the resident laundry department revealed one full rack and one partial rack of unmarked resident personal clothing. During an interview at that time Laundry Aide Employee E3 confirmed: staff do not take unmarked laundry out to the units to enable staff, residents and/or family to identify the owner of the clothing; staff are able to come back to laundry and look for items reported missing by residents/family; family is also able to come back and look through the racks; there is not a process for returning unmarked personal clothing items to residents who are not able to report missing clothing; and once unmarked personal clothing items remain on the racks for a while staff will identify residents in need of a similar size clothing and mark the items for them without first identifying the original owner. During an interview on 5/28/26, at 10:05 a.m. the Nursing Home Administrator confirmed that if residents and/or family report something missing, they are permitted to look for it within the unmarked clothing; there was not a process in place for resident's/families who cannot report missing clothing items; and that the facility staff do not take the unmarked personal clothing items out to the resident units to attempt to identify the owner of the items. 28 Pa. Code 201.14 (a) Responsibility of Licensee28 Pa. Code 201.18 (b)(2)(3)(d) Management28 Pa. Code 201.29 (a) Resident rights

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of five residents reviewed for unnecessary medications (Resident R20). Findings include: Review of facility policy entitled Psychotropic Medication Policy dated 1/21/25, revealed the facility implements gradual dose reductions and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication. Review of Resident R20's clinical record revealed an admitted [DATE], with diagnoses that included osteomyelitis (bone infection) of the right ankle and foot, anxiety, and anemia (condition of not enough healthy red blood cells to carry oxygen). The clinical record revealed that on 4/30/25, Resident R20's physician ordered Lorazepam (a medication ordered to treat anxiety) 0.5 milligrams (mg) every 12 hours PRN for anxiety. Review of Resident R20's May 2025 Medication Administration Record revealed that the PRN Lorazepam was used on 5/4/25, 5/5/25, 5/8/25, and 5/9/25. Resident R20's clinical record lacked evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam for the four administrations in May 2025. During an interview on 5/14/25, at 12:09 p.m. the Director of Nursing confirmed that Resident R20's clinical record lacked evidence that non-pharmacological interventions were attempted prior to the administration of a PRN psychotropic medication for the dates listed above and that non-pharmacological interventions should be attempted and documented in the clinical record. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for two of 20 residents reviewed (Residents R10 and R16). Findings include: Review of facility policy entitled Comprehensive Person-Centered Care Planning dated 1/21/25, indicated The care plans will be reviewed and revised as necessary by the Interdisciplinary Team at least quarterly after each MDS [Minimum Data Set-a periodic assessment of resident care needs] assessment ., or more often as changes occur. Review of Resident R10's clinical record revealed an admitted [DATE], with diagnoses that included diabetes (a health condition that caused by the body's inability to produce enough insulin), gastroesophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Review of Resident R10's physician's orders revealed an order for O2 (oxygen) at 2 LPM (liters per minute) NC (nasal cannula oxygen tubing that has prongs that go into the nostrils and loops around the ears to secure in place to ensure adequate oxygen delivery) routine and PRN (as needed) dated 3/1/25. Review of Resident R10's care plan for alteration in cardio and respiratory lacked an intervention for his/her current use of oxygen. Resident R16's clinical record revealed an admitted [DATE], with diagnoses including Parkinson's disease (a disorder that affects movement related to the central nervous system), major depressive disorder, and moderate intellectual disabilities (limitations to cognitive functioning and skills). Resident R16's clinical record revealed his/her anticoagulant medication Eliquis (a blood thinning medication that reduces the ability to clot) was discontinued on 2/24/25. Resident R16's care plan dated 3/7/25, with a target date of 6/1/25, revealed a care plan was in place related to his/her anticoagulant medication Eliquis. During an interview on 5/14/25, at 1:05 p.m. the Director of Nursing (DON) confirmed that Resident R10's cardio/respiratory care plan was not reviewed/revised to reflect current resident care and services. During an interview on 5/14/25, at 1:45 p.m. the DON confirmed that Resident R16's anticoagulant care plan was not reviewed/revised to reflect current resident care and services. He/she also confirmed that care plans should be reviewed and revised as necessary. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to provide resident privacy during a wound dressing change for one of 22 residents reviewed (Resident R62). Findings include: The facility policy Privacy / Dignity dated 1/10/24, indicated that Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Observation of a wound dressing change for Resident R62 on 6/5/24, at 10:45 a.m. revealed that Licensed Practical Nurse (LPN) Employee E2 and LPN Employee E3 changed wound dressings to the resident's right heel and foot while the roommate was awake and watching the procedure. During an interview on 6/5/24, at 11:15 a.m. LPN Employee E3 confirmed that the privacy curtain should have been pulled. During an interview on 6/5/24, at 11:35 a.m. the Director of Nursing confirmed that during a dressing change the privacy curtain should have been pulled. 28 Pa. Code 211.12(d)(1)(2) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop and implement a resident centered comprehensive care plan for one of 22 residents reviewed (Resident R58). Findings include: A facility policy entitled, Comprehensive Person-Centered Car Planning dated 1/10/24, indicated that a comprehensive person-centered care plan including necessary and appropriate care, attending physicians ordered, services and accommodation of resident needs and preferences for the resident to attain or maintain the highest practicable physical, mental, and psychological well-being will be established within 21 days of admission. Resident R58's clinical record revealed an admitted [DATE], with diagnoses that included pleural effusion (buildup of fluid between the layers of tissue that line the lungs and chest cavity), arthritis, lower back pain, and restless leg syndrome. Resident R58's clinical record included physician's orders dated: 3/06/24, to give 650 milligrams (mg) of acetaminophen every six hours as needed for pain; 3/14/24, to give 650 mg of acetaminophen at bedtime for pain management; 4/01/24, to give 650 mg three times a day for back pain and 650 mg as needed for back pain once daily; and current physician's orders dated 5/09/24, to give 650 mg of Tylenol three times a day for other low back pain, and give 650 mg of Tylenol every four hours as needed for pain, may have one additional dose four plus hours after nine p.m. Resident R58's clinical record lacked evidence of a comprehensive person-centered care plan for pain. During an interview on 6/05/24, at 10:47 a.m. the Director of Nursing confirmed that Resident R58's clinical record lacked evidence of a comprehensive person-centered care plan for pain management. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical records, observation, and staff interview, it was determined that the facility failed to maintain proper care of respiratory equipment for one of four residents reviewed for respiratory care (Resident R29). Findings include: Facility policy entitled Use of Oxygen dated 1/10/24, indicated that the facility changes oxygen cannulas (flexible tubing inserted into the nostrils for oxygen delivery) or masks every 30 days. Resident R29's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (lung disease resulting in difficulty breathing and persistent cough), high blood pressure, and diabetes. Resident R29's physician orders dated 4/5/21, indicated to change oxygen tubing on the 15th of each month. Observations on 6/2/24, at 2:08 p.m. and 6/4/24, at 9:00 a.m. revealed that Resident R29's oxygen tubing contained a piece of white tape wrapped around it with a date of 3/15/24. During an interview on 6/4/24, at 9:22 a.m. Licensed Practical Nurse Employee E1 confirmed that the oxygen tubing was dated for 3/15/24, and was not changed monthly as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, facility documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of three residents reviewed (Resident R1) was free of neglect during care which resulted in actual harm of spiral fractures of the right tibia and fibula (lower leg). This deficiency is cited as past non-compliance. Findings include: A review of facility policy entitled, Resident Abuse & Neglect Prevention Program, dated 1/10/2024, revealed that, Neglect means failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect refers to deprivation by a caretaker of goods, or services which are necessary to maintain physical or mental health. A review of Resident R1's clinical record revealed an admitted [DATE], that included diagnoses of stroke, heart disease, history of falls, and dementia. A review of Resident R1's Quarterly Minimum Data Set assessment (MDS - an assessment tool used to facilitate the management of care) dated 2/28/2024, revealed that Resident R1 required total two-person assistance with transfers. A review of Resident R1's current care plan revealed for transfers resident required, assist of two with front wheeled walker. A review of Resident R1's clinical record revealed a nurse's note dated 4/27/2024, at 9:15 a.m. which indicated that Resident R1 was having some right ankle pain, resident was assessed, and no marks or redness noted, Resident R1 was administered Tylenol (pain medication) and will continue to monitor. A nurse's note dated 4/27/24, at 1:52 p.m. revealed that Resident R1 continued to complain of right ankle pain and was assessed with no swelling or redness noted at that time and was administered Tylenol for pain. A nurse's note dated 4/27/24, at 3:10 p.m. indicated that Resident R1 continued to complain of pain in right leg, resident assessed, and right foot was shiny and slightly swollen and on right shin was a quarter size red area that was tender to touch, right calf was red and warm to touch, also swollen. A nurse's note dated 4/27/2024, at 4:12 p.m. indicated that Resident R1 was sent to the hospital for evaluation. Review of information submitted by facility dated 4/28/2024, revealed Resident R1 was admitted to the hospital with diagnosis of a spiral fracture of the right tibia and fibula. It also revealed that through the investigation that Resident R1 was transferred on 4/27/2024, throughout the day with an assist of one and not an assist of two. A review of the facility's investigation revealed that Nursing Assistant (NA) Employee E1 confirmed on a written statement dated 4/28/2024, he/she transferred Resident R1 in and out of bed with assistance of one. A review of documentation submitted by the facility dated 4/28/2024, revealed that the facility initiated an investigation, regarding Resident R1's injury of unknown origin on 4/27/2024. The investigation revealed that the resident was transferred throughout the day with an assist of one on 4/27/24. Following the transfers, the resident's leg had increased swelling and redness. NA Employee E1 did not follow the resident's care plan resulting in harm and employment was terminated. An interview with the NHA on 5/9/2024, at 10:40 a.m. confirmed that NA Employee E1 transferred Resident R1 alone even though resident was an assist of two. The facility failed to ensure that Resident R1 was free from neglect resulting in actual harm of a spiral fracture of the right tibia and fibula. This deficiency is cited as past non-compliance. On 4/28/2024, the facility initiated education for all nursing staff including Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and NAs to ensure that transfer status must be followed on care plan, with review of abuse and neglect and review of following the care plan. This plan included the following: Immediate suspension of NA Employee E1 followed by termination of employment. Immediate education regarding following the resident's care plan for transfers and abuse/neglect was provided to all facility nursing staff which included RNs, LPNs, and NAs, which occurred from 4/28/2024, to 5/2/2024. All staff included in the education also completed competencies conducted by the Director of Nursing (DON) and the RN Supervisor to ensure that they understood the education and could perform the task correctly. All competencies were reviewed during this on-site investigation. Interviews with RN Employees E2, E3, and E5 and LPN Employee E4 and NA Employees E7, E8, E9, and E10 confirmed the facility initiated education starting 4/28/2024, and competencies starting 5/6/2024, which included education on resident transfer status, following the resident's care plan, and review of abuse / neglect, with knowledge of where to find the resident's care plans. Audits were conducted by the DON of following a resident care plan regarding transfers weekly for three weeks, initial audit of nine resident care plans, monthly times three months and quarterly times one since 5/6/2024. Per interview with the NHA and the DON, audits will continue to be completed by the RN Supervisors on each shift as well as the DON. These audits will be reviewed by the Quality Assurance Performance Improvement (QAPI) Committee. The audits will continue until determined otherwise by the QAPI committee. During an interview with the NHA on 5/9/2024, at 10:40 a.m. and review of the facility's immediate actions, education, competencies, audits, and review of the QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction to ensure residents are free from neglect regarding proper transfers and had achieved substantial compliance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, and resident and staff interviews, it was determined that the facility failed to maintain a clean homelike environment for one of twenty-four residents (Resident R33). Findings include: Observations between 7/26/23, and 7/27/23, revealed Resident R33's arm cradle (a device on a wheelchair that a person's arm lays on when they cannot move that part of their body) was torn the whole way across the front with foam filling coming out. During an interview on 7/27/23, with resident R33 he/she stated that the torn area has been there for a long time and he/she has asked to have the torn arm cradle fixed several times and that it hasn't changed. During an interview on 7/27/23, at 1030 a.m. the Director of Nursing confirmed that the arm cradle was ripped with the foam filling coming out of the front, and that the arm cradle was not appropriate and needed repaired. 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide appropriate urinary catheter (tubing inserted into the bladder to drain urine into a bag) care for one of 20 residents reviewed (Resident R36). Findings include: Review of a facility policy entitled, Urinary Catheters, dated 1/13/23, indicated that the collection bag should be kept off the floor, and covered with a dignity bag. Review of Resident R36's clinical record revealed an admitted [DATE], with diagnoses including kidney failure/disease, disorders of the bladder, and artificial opening of the urinary tract. The clinical record revealed a physician's order for the use of a catheter and to check the catheter every shift for placement and patency. Observation on 7/25/23, at 2:15 p.m. revealed that Resident R36 was in bed with his/her urine collection bag hanging on the side of the bed, uncovered and visible from hallway. Observations on 7/26/23, at 10:00 a.m. and 1:00 p.m. and on 7/27/23, at 8:30 a.m. revealed that Resident R36 was seated in his/her Geri-chair and the urine collection bag was hanging on the back lower frame of the chair, uncovered and resting on the floor. Interview on 7/27/23, at 8:30 a.m. with Registered Nurse Employee E1 confirmed that Resident R36's urine collection bag should have a dignity bag on and not be on the floor. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to prevent the opportunity for potential unauthorized access of medications on one of six medication carts ( A Wing North). Findings include: Review of a facility policy entitled, Medication Administration Control and Security dated 1/31/23, indicated that all medications are to be secured in a locked medication cart until such time as the medication(s) are administered to the resident. Observation on 7/26/23, at 9:44 a.m. revealed that the A Wing North medication cart unsecured and unattended, and had a medication cup of unidentified pills sitting on top, and the top drawer of the cart was ajar. Interview at that time with Registered Nurse Employee E2 confirmed that the cart should have been secured, drawers closed, and no prepared medications on top when the cart is not in view. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy and manufacturer's recommendations, observations, and staff interviews, it was determined that the facility failed to assure that medications were properly dated when opened and discarded in a timely manner on two of two nursing units (A Hall and B Hall), and one of four medication carts (B Hall South). Findings include: Review of manufacturer's recommendations for [MEDICATION(S)] (a long-acting insulin) storage, indicated that opened multi-dose vials of [MEDICATION(S)] are to be stored at room temperature and discarded 42 days after opening. Review of manufacturer's recommendations for [MEDICATION(S)] solution (used to test for [CONDITION(S)]) indicated to label the multi-dose vial when it's opened and discard unused solution 30 days after opening. Review of a facility policy entitled Discontinued Medications dated [DATE], indicated that discontinued medications are to be disposed of or returned to the pharmacy according to the type of medication involved. Observation of drug storage on [DATE], at 1:00 p.m. revealed that the B Hall Medication Room refrigerator contained a ,d+[DATE] empty, opened multi-dose vial of [MEDICATION(S)] solution that lacked an open date, therefore staff were unable to determine the discard date. During an interview at that time Licensed Practical Nurse Employee E1 confirmed that the vial should have been dated when opened and staff are unable to determine the discard date, and should be discarded. Observation of drug storage on [DATE], at 1:29 p.m. revealed that the A Hall Medication Room refrigerator contained a ,d+[DATE] empty, opened multi-dose vial of [MEDICATION(S)] solution that lacked an open date, therefore staff were unable to determine the discard date. During an interview at that time Registered Nurse (RN) Employee E2 confirmed that the vial should have been dated when opened and staff are unable to determine the discard date, and should be discarded. Observation [DATE], at 1:35 p.m. revealed that A Hall North Medication Cart contained an opened multi-dose vial of [MEDICATION(S)] with an opened date of [DATE] (60 days), stored in the medication cart, labeled for Resident R42, and a multi-dose vial of [MEDICATION(S)] stored in the medication cart, labeled for Resident R47 that lacked an opened date, therefore staff were unable to determine the discard date. During an interview at that time RN Employee E3 confirmed that staff were unable to determine the discard date for the opened multi-dose vial of [MEDICATION(S)] lacking an opened date, and that the opened multi-dose vial of [MEDICATION(S)] dated [DATE], was expired and should be discarded. During an interview on [DATE], at 10:20 a.m. the Director of Nursing confirmed that the [MEDICATION(S)] vial opened on [DATE], should have been discarded after 42 days after opening ([DATE]), and that the opened, vials of [MEDICATION(S)] and [MEDICATION(S)] solution should have been dated upon opening. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to accurately develop a baseline care plan within 48 hours of admission for one of 19 residents reviewed (Resident R68). Findings include: Review of facility policy entitled, Comprehensive Person-Centered Care Planning, dated 1/05/21, indicated that a Baseline Care Plan will be completed within 48 hours of admission and will include appropriate interventions to provide an initial set of instructions needed to provide effective and person centered care of the resident. Review of Resident R68's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 10/26/21, at 2:00 p.m. revealed Resident R68 had a foley catheter (tube inserted into the bladder to drain urine). Review of current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a baseline care plan dated 9/28/21, only addressed Activities of Daily Living (ADL) Mobility for Resident R68 and the remaining sections were blank. During an interview on 10/28/21, at 1:00 p.m. the Director of Nursing confirmed that Resident R68's baseline care plan was incomplete and did not reflect the resident's status. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.5(f) Clinical records

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to safely secure medications on one of two nursing units (B Wing). Findings include: Review of facility policy entitled Medication Administration Control and Security, dated 1/05/21, indicated that the nurse must secure the medication cart during the medication pass to prevent unauthorized entry and the medication cart must be securely locked at all times when out of the nurse's view. Medication(s) are secured in a locked Medication Cart or Medication Room until such time as the medication(s) is administered to the resident by a licensed nurse or physician. Observation on 10/26/21, at 4:20 p.m. revealed that Licensed Practical Nurse (LPN) Employee E1 walked away from the medication cart to administer medications, leaving the medication cart in the hallway, unattended, unlocked, and out of view. During an interview on 10/26/21, at 4:42 p.m. LPN Employee E1 confirmed that the medication cart was unattended, unlocked and out of view. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of clinical records, observations and staff interview, it was determined that the facility failed to maintain complete and accurate clinical records regarding an admission assessment and physician's orders for two of 19 residents reviewed (Residents R68 and R86). Findings include: Review of Resident R68's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nurse's note dated 9/28/21, indicated that Resident R68 arrived from the hospital and had a foley catheter (tube inserted into the bladder to drain urine). Review of an Admission Nursing Evaluation dated 9/28/21, did not reflect that Resident R68 had a foley catheter. Observation on 10/26/21, at 2:00 p.m. revealed Resident R68 had a foley catheter. Review of current physician's orders revealed orders for an indwelling foley catheter for Resident R68. During an interview on 10/28/21, at 1:00 p.m. the Director of Nursing confirmed that Resident R68's clinical record and admission nursing evaluation was inaccurate and did not reflect the resident's catheter. Review of Resident R86's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R86's care plan for Alteration in Cardio/Respiratory Status noted Oxygen per order was initiated on 10/11/21. Observations on 10/26/21, at 2:10 p.m. and 10/29/21, 10:09 a.m. revealed Resident R86 receiving oxygen therapy via nasal cannula (a device inserted into the nose used to deliver supplemental oxygen). Review of current physician's orders dated 10/29/21, revealed no orders for oxygen therapy. During an interview on 10/29/21, at 9:54 a.m. the Director of Nursing confirmed that the clinical record and physician's orders did not reflect that oxygen therapy was to be administered to Resident R86. 28 Pa.Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f) Clinical records

Based on observations and staff interviews it was determined that the facility failed to perform hand hygiene between direct contact with residents during meal tray delivery for 19 out of 95 residents (A-2 Wing). Findings include: Observation of meal tray delivery on 9/28/20, between 12:05 p.m. and 12:28 p.m. revealed that Nurse Aide (NA) Employee E4 and NA Employee E5 delivered meal trays and assisted residents to set-up (including direct contact with the resident, moving personal items from tray tables, and manipulating resident's position) for resident rooms 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 130, and 131 and failed to perform hand hygiene upon entering and exiting resident rooms during delivery of meal trays. Interviews on 9/28/20, at 12:30 p.m. with NA Employees E4 and E5 confirmed they did not perform hand hygiene upon entering and exiting each resident room during delivery of meal trays on the A-2 Wing, or 19 residents. During an interview on 9/28/20, at 1:15 p.m. the Assistant Director of Nursing confirmed that staff should have performed hand hygiene upon entering and exiting resident rooms during delivery of meal trays. 28 PA Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to safely secure medications on one of two nursing units (B Wing). Findings include: The facility policy entitled Keys-Medication Room / Medication Cart, dated 1/06/20, indicated that the medication cart must be securely locked at all times when out of the nurse's view. Observation on 3/08/20, at 10:00 a.m. revealed a medication cart on B Wing in the hallway unlocked, unattended and out of view of the nurse. During an interview on 3/08/20, at 10:05 a.m. Registered Nurse Employee E1 confirmed that the unlocked medication cart was unattended and out of view. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of clinical records, facility documentation, facility policy, and staff interview, it was determined that the facility failed to follow nursing standards of practice related to medication administration for one of three residents reviewed (Resident R2). Findings include: Facility policy titled Medication Administration dated 1/6/2020, revealed .to provide safe administration of all medications .the licensed nurse will check the following to administer medication: right medication, right dose, right dosage form, right route, right resident, and right time. The policy also indicated that the proper procedure included to verify the pharmacy prescription label on the drug and the manufacturer's identification system matches the Medication Administration Record [REDACTED] Resident R2's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Facility documentation revealed a receipt dated 1/16/2020, for [MEDICATION NAME] (a medication used as an appetite stimulant) 15 milligrams received by the facility from the pharmacy for Resident R2. Resident R2's January 2020 monthly physician's orders [REDACTED]. An Incident/Accident Report regarding the dates 1/17/2020, 1/18/2020, and 1/19/2020, revealed that Resident R2 was administered three doses of [MEDICATION NAME] on the above dates by Licensed Practical Nurses (LPN) Employees E1 and E2 as it was discovered in the medication cart. Professional nursing standards to include verifying the label on the drug matched the MAR indicated [REDACTED]. During an interview on 2/25/2020, at 1:50 p.m. the Director of Nursing confirmed that LPNs Employees E1 and E2 did not follow professional nursing standards regarding medication administration to Resident R2. 28 PA Code 211.12(d)(1)(3)(5) Nursing services 28 PA Code 201.14(a) Responsibility of licensee

Based on review of clinical records, facility documentation, and staff interview, it was determined that the facility administered a medication without a physician's orders [REDACTED]. Findings include: Resident R2's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Facility documentation revealed a receipt dated 1/16/2020, for [MEDICATION NAME] (a medication used as an appetite stimulant) 15 milligrams received by the facility from the pharmacy for Resident R2. Resident R2's January 2020 monthly physician's orders [REDACTED]. An Incident/Accident Report regarding the dates 1/17/2020, 1/18/2020, and 1/19/2020, revealed that Resident R2 was administered three doses of [MEDICATION NAME] on the above dates without a physician's orders [REDACTED].>During an interview on interview on 2/25/2020, at 1:50 p.m. the Director of Nursing confirmed that Resident R2 was administered three doses of [MEDICATION NAME] in error without a physician's orders [REDACTED].>42 CFR 483.25 Quality of Care Previously cited deficiency 1/3/2020 28 PA Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, review of clinical records, facility policies and documentation, and staff interviews, it was determined that the facility failed to ensure adequate safety measures were implemented by attaching foot rests (supportive device attached to a wheelchair for the feet to rest upon) to the wheelchair during transport that resulted in actual harm of a scapula (shoulder blade) fracture to one of 25 residents reviewed (Resident R26). Findings include: The facility policy regarding the use of wheelchairs, dated 1/02/19, revealed that foot rests were to be used when transporting residents in a wheelchair. An Annual MDS dated [DATE], revealed that Resident R26 had [DIAGNOSES REDACTED]. Facility documentation revealed that on 7/02/18 and 7/03/18, all staff had been educated regarding the importance of using foot rests on wheelchairs while transporting residents to maintain safety. Resident R26's care plan dated 7/12/18, revealed that a right leg foot rest was to be utilized while in the wheelchair. The facility investigation regarding an incident on 7/16/18, revealed that at approximately 10:00 a.m. Nurse Aide (NA) Employee E7 was transporting Resident R26 up the hallway in his/her wheelchair. Resident R26 suddenly put his/her foot down onto the floor and then fell forward from the wheelchair onto the floor. Upon assessment by Registered Nurse Employee E2, there was a hematoma (an area of a collection of blood caused by a break in a blood vessel) to the forehead. Additional documentation revealed at approximately 8:35 p.m. Resident R26 started to display a change in mental status and was sent to the emergency room as ordered by the physician. The investigation discovered that foot rests were not on the wheelchair during the transport. The facility's investigation concluded that NA Employee E7 violated the facility's policy to use foot rests while transporting Resident R26 in his/her wheelchair. Information submitted by the facility dated, 7/21/18, revealed that while Resident R26 was in the hospital x-rays were completed on 7/18/18, on Resident R26's right shoulder which showed an oblique fracture through the scapular body. During an interview on 5/16/19, at 11:25 a.m. the Director of Nursing confirmed that NA Employee E7 did not use the foot rest on Resident R26's wheelchair during transport that resulted in actual harm of a scapular fracture. Observation on 5/15/19, at 1:29 p.m. revealed that Employee E5 did not utilize foot rests on the wheelchair while propelling Resident R93 by wheelchair down the hall of A-Wing. Observation on 5/15/19, at 2:22 p.m. revealed that NA Employee E2 did not utilize foot rests on the wheelchair while propelling Resident R68 by wheelchair down the hall of A-Wing. NA Employee E2 was heard verbally reminding Resident R68 to keep his/her feet up. Observation on 5/15/19, at 2:40 p.m. revealed that Employee E6 did not utilize foot rests on the wheelchair while propelling Resident R37 by wheelchair down the hall of A-Wing. Observation on 5/16/19, at 11:30 a.m. revealed that Resident R80 was sitting in the entrance of the building watching people come in and out of the door and NA Employee E8 explained it was time to get ready for lunch, pushing Resident R80 down the hall to the nursing station without utilizing foot rests. At 12:05 p.m. Resident R80 was noted again sitting in front of the entrance people watching when NA Employee E8 again pushed Resident R80 down the hall and into the dining area without foot rests on the wheelchair. Observation on 5/16/19, at 11:53 a.m. revealed that NA Employee E4 did not utilize foot rests on the wheelchair while propelling Resident R43 by wheelchair out of A-Wing shower room. Observation on 5/16/19, at 11:54 a.m. revealed that NA Employee E1 did not utilize foot rests on the wheelchair while propelling Resident R24 by wheelchair out of A-Wing shower room. Observation on 5/16/19, at 11:59 a.m. revealed that NA Employee E1 did not utilize foot rests on the wheelchair while propelling Resident R29 by wheelchair down the hall of A-Wing. NA Employee E1 was heard verbally reminding Resident R29 to keep his/her feet up. Observation on 5/16/19, at 12:15 p.m. revealed that NA Employee E3 failed to utilize foot rests on the wheelchair while propelling Resident R13 by wheelchair down the hall of A-Wing. NA Employee E3 was heard verbally reminding Resident R13 to keep his/her feet up. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.19(d) Resident rights 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services Previously cited 4/06/18