Every finding on record at Elm Terrace Gardens

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity for three of 19 sampled residents in one of two dining areas. (Second Floor) (Residents 18, 27, 54) Findings include: Clinical record review revealed that Resident 18 had diagnoses that included Alzheimer's disease and dysphagia, oral phase (difficulty chewing before swallowing). Review of the Minimum Data Set (MDS) assessment, dated February 27, 2025, revealed that the resident had cognitive impairment and needed assistance from staff with eating. Review of Resident 18's care plan revealed that staff was to provide total assistance with feeding. Resident 27 had diagnoses that include Alzheimer's disease and dysphagia, oropharyngeal phase (difficulty swallowing). Review of the MDS dated [DATE], revealed that the resident had cognitive impairment and needed staff assistance with eating. Review of Resident 27's care plan revealed that staff was to provide total assistance with feeding. Resident 54 had diagnoses that include frontotemporal neurocognitive disorder. Review of the MDS dated [DATE], revealed that the resident had cognitive impairment and needed assistance from staff with eating. Review of Resident 54's care plan revealed that staff was to provide total assistance with feeding. On March 25, 2025, from 12:45 p.m. through 1:05 p.m., nurse aide (NA) 1 was observed standing while assisting Residents 18, 27, and 54 with lunch. On March 25, 2025, from 12:37 p.m. through 12:45 p.m., NA 2 was observed standing while assisting Resident 27 with lunch. In an interview on March 27, 2025, at 10:04 a.m., the Administrator stated that staff were not to stand over residents while feeding them. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on policy review, observation, and staff interview, it was determined that the facility failed to serve food in a sanitary manner in one of two dining areas (Second Floor). Findings include: Review of the facility's policy, Hand Washing/Hand Hygiene, dated January 7, 2025, revealed staff was expected to wash their hands and wear disposable gloves that are replaced between tasks during which they may have been soiled. On March 25, 2025, from 12:50 p.m. to 1:25 p.m. Dietary Aide 1 was observed wearing one pair of gloves to assist resident 27 with utensils, clear soiled plates, and assist with preparing plates of food for other residents. At no time did Dietary Aide 1 change gloves between tasks. In an interview on March 27, 2025, at 10:04 a.m., the Administrator stated that staff completing dining tasks were to change disposable gloves between tasks. 28 Pa. Code 201.14(a) Responsibility of licensee.

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 accurately to reflect the current status of one of 19 sampled residents. (Resident 8) Findings include: Clinical record review revealed that Resident 8 was admitted to the facility on [DATE]. Review of an admission nursing assessment, dated March 1, 2025, revealed a lack of evidence that the resident had a pressure ulcer upon admission. In an interview on March 26, 2025, at 11:10 a.m., Registered Nurse 1 stated that the resident did not have any pressure ulcers during his admission to the facility. Review of section M of the MDS assessment, which assessed skin conditions, dated March 7, 2025, indicated that the resident had a stage two pressure ulcer that was present upon admission. There was a lack of evidence to indicate that the resident had a stage two pressure ulcer while in the facility. In an interview on March 27, 2025, at 9:46 a.m., the Director of Nursing confirmed that the MDS assessment was not accurate.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement care planned interventions for one of 19 sampled residents. (Resident 13) Findings include: Clinical record review revealed that Resident 13 was admitted to the facility on [DATE], and had diagnoses that included a stroke with remaining weakness to one side of the body and altered mental status. According to the Minimum Data Set assessment dated [DATE], the resident was cognitively impaired and had sustained falls on two occasions since admission. A review of the care plan revealed that the resident had a risk for falls related to confusion and lack of safety awareness and staff was to place the fall mat on left side of the bed while in bed and to check placement every shift. Observations on May 15, 2024, at 9:40 a.m., and May 16, 2024, at 9:01 a.m., revealed Resident 13 was in bed with no fall mat to the left side of the bed. In an interview on May 17, 2024, at 11:17 a.m., the Community Registered Nurse Educator stated that the fall mat should have been in place when the resident was in bed. CFR. 483.21(b)(1) Comprehensive Care Plans Previously cited 6/1/23. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and observation, it was determined that the facility failed to ensure that adaptive equipment was provided to two of 19 sampled residents. (Residents 21, 44) Findings include: Clinical record review revealed that Resident 21 had diagnoses that included Parkinson's disease, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side (weakness or the inability to move on one side of the body after a stroke), and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 21 required limited assistance with eating and had a functional limitation in range of motion on one side of his upper extremities. A physician's order dated March 30, 2023, directed staff to serve the resident a puree diet on a sectioned plate with a left curved spoon with built up handle. Observation on May 30, 2023, from 12:28 p.m., through 1:00 p.m., revealed Resident 21 was served lunch on a regular plate. Resident 21 was observed on May 31, 2023, from 10:18 a.m., through 10:35 a.m., in bed with breakfast and had a regular spoon and a regular plate. Resident 21 proceeded to eat breakfast with the regular spoon, spilling food onto the table and clothing protector. Resident 21 was not provided a sectioned plate and left curved spoon with built up handle as the physician had ordered. Clinical record review revealed that Resident 44 had diagnoses that included depression, anxiety, dementia, and dysphagia. Review of the MDS assessment dated [DATE], revealed that the resident required supervision for eating. Review of the care plan revealed the resident was at risk for weight loss and interventions included that staff provide a scoop dish with meals. A physician's order dated January 28, 2022, directed staff to serve the resident a puree diet on a scoop dish. Observation on May 31, 2023, at 12:07 p.m., through 12:40 p.m., revealed the resident was served a puree diet on a regular plate. The resident proceeded to eat the meal from a regular plate and food items were spilling onto the resident's clothing protector. Resident 44 was not provided with a scoop dish per the plan of care or physician's order. 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 physician's orders were implemented for two of 19 sampled residents. (Residents 58, 62) Findings include: Clinical record review revealed that Resident 58 had diagnoses that included hypertension and dementia. A physician's order dated May 18, 2023, directed staff to administer a medication for high blood pressure (diltiazem) once daily unless the heart rate was less than 65 beats per minute (bpm). A review of the May 2023, medication administration record (MAR) revealed that staff administered the medication when the heart rate was less than 65 bpm on two occasions. In an interview on June 1, 2023, at 10:51 a.m., the Director of Nursing (DON) confirmed that the medication was administered outside of the established parameters for Resident 58. Clinical record review revealed that Resident 62 had diagnoses that included hypotension. A physician's order dated April 25, 2023, directed staff to administer a medication (fludrocortisone acetate) once daily unless the systolic blood pressure (SBP) was greater than 140 millimeters of mercury (mmHg). On May 17, 2023, the physician ordered to withhold the medication if the SBP was greater than 110 mmHg. Review of the May 2023 MAR revealed staff administered the medication 14 times outside of the established parameters. A physician's order dated April 5, 2023, directed staff to administer a medication (midodrine) once daily unless the SBP was greater than 140 mmHg. On May 16, 2023, the physician ordered to withhold the medication if the SBP was greater than 110 mmHg. Review of the May 2023 MAR revealed staff administered the medication six times outside of the established parameters In an interview on June 1, 2023, at 11:33 a.m., the DON confirmed that the medications were administered outside of established parameters for Resident 62. 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 develop a care plan with interventions to address an identified problem area for two of 18 sampled residents. (Residents 58, 68) Findings include: Clinical record review revealed that Resident 58 had diagnoses that included depression. Physician orders dated May 18, 2023, directed staff to administer antidepressant medications (fluoxetine and bupropion) daily for depression. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was administered antidepressant medications on five occasions during the review period. Review of the Care Area Assessment (CAA) summary identified the use of antidepressant medications as a problem to be care planned. Review of the care plan revealed there were no interventions included to address the use of antidepressant medication. In an interview on June 1, 2023, at 10:51 a.m., the Director of Nursing (DON) confirmed there had been no care plan developed for the use of antidepressant medications for Resident 58. Clinical record review revealed that Resident 68 was admitted to the facility on [DATE], with diagnoses that included fatigue fracture of vertebra, sacral and sacrococcygeal region (broken pelvis), dorsalgia (back pain), and legal blindness. Review of the MDS assessment dated [DATE], revealed that the resident had urinary incontinence and decreased mobility. The CAA identified urinary incontinence and pressure ulcer as problem areas to be care planned. Review of Resident 68's current care plan did not include interventions to address urinary incontinence or the pressure ulcer. In an interview on June 1, 2023, at 10:56 a.m., the DON confirmed that there had been no care plan developed to address these CAA areas for Resident 68. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observation, it was determined that the facility failed to provide a safe, sanitary and comfortable environment on two of four nursing units. (Nursing units D-1A and D-1B) Findings include: Observation throughout the facility during all days of the survey revealed the following: A lift (used to transfer residents from surface to surface) labeled 450 on Unit D-1A had dirty wheels. A lift labeled 600 on Unit D-1B had dirty wheels Observations on May 30, 2023, at 12:07 p.m., and May 31, 2023, at 12:25 p.m., revealed the oxygen concentrator filter was dusty and dirty. Resident 35 was observed using the oxygen concentrator on May 30, 2023, at 2:10 p.m. 28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review and staff interview it was determined that the facility failed to notify the resident, the resident's representative(s), and the local ombudsman of the transfer and the reasons for transfer in writing for seven of seven sampled residents who were transferred to the hospital. (Residents 2, 20, 23, 35, 55, 62, 66) Findings include: Clinical record review revealed that Resident 2 was transferred and admitted to the hospital on April 7, 2023, and April 28, 2023, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, and the ombudsman were provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 20 was transferred and admitted to the hospital on April 24, 2023, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, and the ombudsman were provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 23 was transferred and admitted to the hospital on April 17, 2023, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, and the ombudsman were provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 35 was transferred and admitted to the hospital on January 11, 2023, February 1, 2023, and May 17, 2023, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, and the ombudsman were provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 55 was transferred and admitted to the hospital on April 30, 2023, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, and the ombudsman were provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 62 was transferred and admitted to the hospital on April 3, 2023, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, and the ombudsman were provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 66 was transferred and admitted to the hospital on March 10, 2023, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, and the ombudsman were provided written information regarding the resident's transfer to the hospital. In an interview on May 31, 2023, at 12:38 p.m., the Director of Nursing stated that the identified residents, residents' representatives, and the local ombudsman were not notified in writing of the transfer to the hospital.

Based on clinical record review and observation, it was determined that the facility failed to ensure that resident dignity was promoted for one of 18 sampled residents. (Resident 4) Findings include: Clinical record review revealed that Resident 4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment, required extensive assistance from staff for dressing and limited assistance from staff for eating. Review of the current care plan identified that the resident had a self care deficit due to cognitive impairment. Observation on June 22, 2022, at 10:32 a.m., revealed Resident 4 was dressed and seated in his wheelchair near the nursing unit. Resident 4 had on a white t-shirt that was heavily stained and soiled. Resident 4 remained in this same soiled t-shirt throughout the day. Observation on June 22, 2022, at 12:45 p.m., through 1:25 p.m., revealed that Resident 4 was seated at a table in the dining room. At the table, was Resident 33, who was served her lunch and she was being assisted to eat her meal by her spouse. At the same time, Resident 4 was served his drinks, a bowl of soup and a sandwich. Resident 4 was unable to feed himself and was observed leaning forward with his head almost touching his food. Resident 4 had also dropped one of his drinks into his lap. Throughout the observation, Resident 4 watched Resident 33 eat her meal and Resident 4 did not receive any assistance from staff until 40 minutes after he had received his meal. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, review of incident reports, observation and staff interview, it was determined that the facility failed to ensure that staff provided adequate supervision in order to prevent falls for two of seven sampled residents who were at risk for falls. (Resident 35, 68) In addition, the facility failed to ensure that assessed safety interventions were in place to prevent skin tears for one of seven sampled residents who were at risk for falls and skin tears. (Resident 9) Findings include: Clinical record review revealed that Resident 35 had diagnoses that included dementia and anxiety. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had memory impairment, required extensive assistance from staff for activities of daily living, was not steady moving from a seated to a standing position and had a history of two or more falls. Review of a fall risk assessment dated [DATE], revealed that the resident was at a high risk for falls due to memory impairment, agitated behavior, being confined to a chair and a loss of balance while standing. Review of nursing documentation and incident reports revealed that Resident 35 had fallen eight times between October 19, 2021 and January 11, 2022. The falls occurred in various areas on the nursing unit. All eight of the falls were out of her wheelchair and occurred between the hours of 3:00 p.m., through 8:45 p.m. Review of incident reports revealed that the resident fell out of her wheelchair on October 19, 2021, and again on November 11, 12, and 15, 2021. Review of nursing documentation dated November 16, 2021, at 6:29 p.m., revealed that the resident kept trying to get in and out of her wheelchair during the shift. On November 18, 2021, at 6:49 p.m., a nurse noted that the resident had to be redirected throughout the shift to stay in her wheelchair. On December 5, 2021, at 3:01 p.m., a nurse noted that the resident had fallen out of her chair. Nursing documentation for the same day at 8:04 p.m., revealed that the resident had opened the door at the back hallway of the nursing unit and was saying she was going to get her car. On December 18, 2021, at 9:44 a.m., the resident was noted as standing up from her wheelchair. Review of nursing notes and incident reports revealed that the resident fell again on December 29, 2021, at 6:21 p.m., as she had stood up from her wheelchair and started to walk without assistance and fell to the floor. On January 11, 2022, at 8:25 p.m., a nurse noted that she was again trying to get out the exit door on the nursing unit and slid out of her wheelchair. There was no documented evidence that the facility provided adequate supervision at the times the resident had exhibited unsafe behaviors, specifically attempts at unassisted transfers out of her wheelchair in order to prevent falls. Clinical record review revealed that Resident 68 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], diabetes and hypertension (high blood pressure). The MDS assessment dated [DATE], indicated that the resident had memory impairment, required extensive assistance with transfers and activities of daily living, was not steady with walking or moving from a seated to a standing position and had a history of falls. Review of a fall risk assessment dated [DATE], revealed that the resident was at risk for falls due to a history of falls and being disoriented to person, place and time at all times. Review of the current care plan identified the resident was at risk for falls related to poor safety awareness. Review of nursing documentation and incident reports revealed that the resident fell 24 times between March 21, 2022 and June 20, 2022. The falls occurred in various areas of the nursing unit. Twenty-two of the falls were out of his wheelchair. Review of nursing documentation dated March 17, 19, 20 and 21, 2022, revealed that the resident was making multiple attempts to transfer and walk unassisted by staff. Resident 68 fell on [DATE] and 22, 2022, and April 2, 3, 5, 11 and 16, 2022. On April 17 and 18, 2022, nurses noted that the resident was exit seeking and making multiple attempts to get out of his wheelchair unassisted. Resident 68 fell on [DATE], 29, and 30, 2022, and May 1 and 6, 2022. On May 7, 2022, a nurse noted that the resident was attempting to get up unassisted from his wheelchair several times during the shift. On May 8, 2022, a nurse noted that the resident had increased agitation and he was making multiple attempts to transfer unassisted by staff. Resident 68 fell on [DATE] and 28, 2022. A nurse noted on May 30, 2022, that the resident required redirection throughout the shift to not get up from his chair unassisted by staff. Resident 68 again experienced falls on June 5, 14, 16, and 20, 2022 and twice on June 17, 2022. There was no documented evidence that the facility provided adequate supervision when the resident was exhibiting unsafe behaviors, specifically attempts at unassisted transfers out of his wheelchair in order to prevent falls. In an interview on June 23, 2022, at 11:50 a.m., the Director of Nursing stated that the facility had failed to provide adequate supervision in order to prevent falls for the two residents. Clinical record review revealed that Resident 9 had diagnoses that included [CONDITION(S)] and a history of a [CONDITION(S)]. The MDS assessment dated [DATE], indicated that the resident was alert and oriented and required limited assistance from staff with dressing. Review of an incident report dated May 5, 2022, revealed that the resident had fallen in her room and sustained two skin tears on her right upper extremity and a bruise on her left forearm. A new intervention was implemented at this time for staff to apply bilateral geri-sleeves, protective skin sleeves, to her upper extremities at all times. Observation on June 22, 2022, at 11:00 a.m., 12:00 p.m., and 1:30 p.m., revealed that the resident did not have the geri-sleeves in place. In an interview on June 23, 2022, at 1:05 p.m., the Director of Nursing stated that the resident was to have the protective skin sleeves in place and that there was no accountability for staff application of the skin sleeves on a daily basis. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to post accurate and current nusing staffing information on one of two nursing units. (Second floor nursing unit) Findings include: Observation on June 22, 2022, at 10:00 a.m,. and again at 1:04 p.m., revealed that the nursing staffing information that was posted on the second floor nursing unit was dated June 20, 2022. The information included the staffing numbers and census for June 20, 2022, not for the current date of June 22, 2022.

Based on clinical record review and resident interview, it was determined that the facility failed to provide restorative nursing services to prevent a reduction in range of motion and/or to improve or maintain mobility for one of 18 sampled residents. (Resident 17) Findings include: Clinical record review revealed that Resident 17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], indicated that the resident was not cognitively impaired, required staff assistance for transfers and walking, and had limited range of motion of her legs on one side. Review of Resident 17's current plan of care revealed that she had an overall functional decline and was put on a restorative nursing program on May 19, 2021. Staff was to provide close supervision to Resident 17 while walking to the bathroom and dining room, up to 500 feet. In an interview on July 1, 2021, at 9:50 a.m., Resident 17 stated that staff does not offer to walk her consistently and that she desired to walk daily. Review of nursing documentation from June 2, 2021, through July 1, 2021, revealed there was a lack of documentation to support that the resident received restorative nursing services 12 of the 30 days. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that pharmacy recommendations were acknowledged timely by the physician for two of 18 sampled residents. (Residents 4, 24) Findings include: Clinical record review revealed that Resident 4 had diagnoses that included Alzheimer's disease, dementia, anxiety, and delusional disorder. On April 22, 2021, the pharmacist recommended Resident 4's physician consider eliminating one of two medications (mirtazapine and melatonin) the resident was receiving for [CONDITION(S)]. If this could not be accomplished, the physician was to document a brief rationale. There was no documented evidence that Resident 4's physician addressed the pharmacist's recommendation. Clinical record review revealed that 24 has diagnoses that included depression and seizures. On May 26, 2021, the pharamacist recommended Resident 24's physician consider a dose reduction for an antihistamine (Zyrtec) due to the resident's age. If a dose reduction could not be accomplished the physician was to document a brief rationale. There was no documented evidence that the physician addressed the pharmacist's recommendation. In an interview, on July 1, 2021, at 12:20 p.m., the Director of Nursing confirmed that the physician did not address Resident 4 and 24's recommendations from the pharmacist. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, staff interview and clinical record review, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis and failed to ensure that pain management was consistent with professional standards of practice for three of 17 residents. (Residents 28, 32, 49) Findings include: Review of the facility policy entitled, Pain Management, dated September 12, 2019, revealed that the nursing staff was to assess the resident's level of pain using a scale of one to ten. The scale was to be divided accordingly: one to four would be associated with mild pain, five to seven would be associated with moderate pain and eight to ten would be associated with severe pain. The staff was to medicate the resident with the appropriate medication based on the resident's pain level and the physician's order. Clinical record review revealed that Resident 28 had [DIAGNOSES REDACTED]. On June 19, 2018, a physician ordered for staff to administer an as needed pain medication (Tylenol) every six hours for mild pain. On November 16, 2018, a physician ordered for staff to administer an as needed pain medication ([MEDICATION NAME]) every eight hours for moderate pain. On December 20, 2019, a physician also ordered an as needed pain medication ([MEDICATION NAME]) every six hours for pain. Review of the Medication Administration Record [REDACTED]. There was no documentation to support that prior to administering the pain medications staff attempted non-pharmacological interventions 24 times in December and January. There was no documentation to support that staff identified the resident's level of pain as mild, moderate, or severe to ensure that the correct pain medication was administered. Clinical record review revealed that Resident 32 had [DIAGNOSES REDACTED]. On November 20, 2019, a physician ordered for staff to administer an as needed pain medication ([MEDICATION NAME]) every fours hours for unspecified pain. On November 20, 2019, a physician also ordered an as needed pain medication (Tylenol) every six hours as needed for mild pain. Review of the MAR indicated [REDACTED]. There was no documentation to support that prior to administering the pain medications staff attempted non-pharmacological interventions 26 times in December and January. There was no documentation to support that staff identified the resident's level of pain as mild, moderate, or severe to ensure that the correct pain medication was administered. Clinical record review revealed that Resident 49 had [DIAGNOSES REDACTED]. On [DATE], the physician ordered for staff to administer pain medication ([MEDICATION NAME]) every six hours as needed for mild to moderate pain and on December 12, 2019, to administer pain medication ([MEDICATION NAME] sulfate solution) every 4 hours as needed for severe pain. Review of the December 2019, MAR indicated [REDACTED]. In addition, based on policy review, the facility failed to provide the correct medication for assessed pain level on three of 13 occasions. During an interview on January 10, 2020, at 12:44 p.m., the Director of Nursing confirmed that there was no documentation to support that staff was attempting non-pharmacological interventions consistently or that staff was identifying the resident's level of pain and administering the correct pain medication based on doctor order and facility policy. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 1/4/19

Based on clinical record review and facility incident report review, it was determined that the facility failed to implement necessary interventions to prevent accidents for one of 17 sampled residents. (Resident 49) Findings include: Clinical record review revealed that Resident 49 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment, dated November 22, 2019, indicated that the resident had memory problems and required extensive staff assistance for activities of daily living such as transferring between surfaces and walking. Review of the facility incident report, dated August 4, 2019, at 6:30 a.m., revealed that Resident 49 experienced an unwitnessed fall and was found sitting on the floor next to her bed, stating I just had to get up and I got up and I fell . It was determined that, just prior to the fall, the resident had been taken to the toilet, dressed, and put back to bed by the nurse aide. As a result of the fall, an additional intervention was added to the resident's care plan on August 4, 2019, that directed staff to take the resident to the nurses' station after care. Review of the facility incident report, dated December 5, 2019, at 7:45 a.m., revealed that Resident 49 experienced an unwitnessed fall and was found lying on the floor next to the bed. It was noted that the resident was attempting to get out of bed without assistance after being provided with care, dressed by staff, and left in bed at 6:00 a.m. The facility failed to ensure that the resident was taken to the nurses' station after care, putting the resident at risk for falling. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 1/4/19

Based on clinical record review and staff interview, it was determined that the facility failed to indicate the duration and provide non-pharmacological interventions prior to administering a [MEDICAL CONDITION] medication prescribed to be given as needed for one of 17 sampled residents. (Resident 49) Findings include: Clinical record review revealed that Resident 49 had [DIAGNOSES REDACTED]. The resident was ordered by the physician on [DATE], to receive [MEDICATION NAME] .5 milligrams (mg) every 24 hours as needed (PRN) for anxiety. The facility failed to indicate the duration of the PRN [MEDICATION NAME] order and it was administered on five occasions, including January 2, 2020, January 4, 2020, and January 5, 2020; a duration exceeding 14 days. In addition, there was a lack of documentation to support that non-pharmacological interventions were provided to Resident 49 prior to the administration of the PRN [MEDICAL CONDITION] medication in accordance with the plan of care. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 1/4/19 28 Pa. Code 211.12(d)(3) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to notify residents and residents' representatives of transfers and the reasons for the moves in writing upon transfer from the facility for one of 17 sampled residents. (Resident 48) Findings include: Clinical record review revealed that Resident 48 was transferred and admitted to the hospital on September 10, 2019, after a change in condition. There was no documented evidence that the resident and the resident's responsible party was provided written information regarding the resident's transfer to the hospital. In an interview conducted on January 10, 2020, at 12:47 p.m., the Director of Nursing confirmed that no written transfer notices were given to the resident or the residents' representatives when transferred out of the facility.

Based on clinical record review, observation and staff interview, it was determined that the facility failed to implement care planned interventions for one of 17 sampled residents. (Resident 3) Findings include: Clinical record review revealed that Resident 3 had [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment dated (MONTH) 25, (YEAR), revealed that the resident was totally dependent on staff for bathing and personal hygiene. The current care plan revealed the resident required staff assistance to maintain an optimal quality of life. The care plan indicated that the resident was to receive showers and nail care twice a week on Tuesdays and Fridays. Review of the clinical record revealed that the resident had not received a shower in the past 30 days. Observation on (MONTH) 3, 2019, at 1:30 p.m., revealed that the resident's nails were uncut and dirty. In an interview on (MONTH) 4, 2019, at 9:30 a.m., the Director of Nursing confirmed that the resident had not received showers as indicated in the care plan. 28 Pa. code 211.12(d)(1)(5) Nursing services

Based on clinical record review, policy review, observation and staff interview, it was determined that the facility failed to ensure that infection control practices were implemented to reduce the potential spread of infection for one of four residents on transmission based precautions out of a sample of 17 residents. (Resident 60) Findings include: Review of the facility's [MEDICAL CONDITION] policy last reviewed on (MONTH) 18, (YEAR), revealed that residents being treated for [REDACTED]. The policy directed staff to wear gowns and gloves when entering the room, remove gowns and gloves prior to exiting the room, and immediately wash their hands before leaving the room of a resident on contact precautions for [MEDICAL CONDITION]. Clinical record review revealed that Resident 60 was readmitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. On (MONTH) 21, (YEAR), finalized laboratory results confirmed [MEDICAL CONDITION] and directed staff to administer an antibiotic to treat this infection. On (MONTH) 2, 2019, at 11:16 a.m. a housekeeper (Employee 1) provided environmental services to Resident 60's room. Employee 1 came into contact with the resident's voiding commode, bed, furniture and resident care equipment (call bell). Employee 1 failed to wear a gown while providing services and failed to remove their gloves and immediately wash their hands when leaving the resident's room. In an interview on (MONTH) 2, 2019, at 12:10 p.m. the facility's Infection Control Nurse stated that Resident 60 was on contact precautions and Employee 1 should have worn a gown when entering the resident's room and immediately removed her gloves and washed their hands prior to leaving the room. 28 Pa. code 211.10(d) Resident care policies.