Every finding on record at Fairmount Homes

Based on observations, review of the facility's policy and clinical records, and staff interviews, it was determined that the facility failed to consistently and closely monitor a resident exhibiting psychotropic medication side effects and failed to provide a rationale for extended use of an antianxiety medication for two of five residents reviewed (Resident 42 and 79). Findings include: A review of the facility's policy titled Psychotropic Medication/Behavioral Management Policy, last reviewed in March 2026, revealed that PRN (as needed) orders are limited to 14 days for all psychotropic medications (Any medication that affects the brain activity associated with mental processes and behaviors). The same policy stated, If the attending practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document the rationale in the resident's clinical records. The same policy revealed, All residents on psychotropic medication are discussed at least monthly at the Behavioral Management Committee meeting. A review of Resident 42's diagnosis list includes bipolar disorder (A Disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Psychosis (A severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality), Anxiety disorder (A mental health disorder characterized by feeling of worry, anxiety or fear that are strong enough to interfere with one's daily activities), and Major depressive disorder (Characterized by a low mood or loss of interest in activities that last for a long time that can interfere with normal functioning). A review of Review of Resident 42's medications list includes medications Ativan 1 mg (milligram) daily (anti-anxiety medication), Pristiq 50 mg daily (anti-depressant medications), Depakote 500mg twice daily (medication for seizure and mood disorders), and [NAME] 20mg twice a day (anti-psychotic medication). A review of Resident 42's clinical record, Behavior Management Committee Summary, revealed that on April 28, 2026, Staff have noticed newly observed repetitive oral/facial movements, described as opening and closing mouth movements. This appears to be a new finding and may represent dyskinesia (An impairment of voluntary movement resulting in unwanted, uncontrollable, and involuntary muscle movements) or another extrapyramidal side-effect (EPS- drug-induced disorders caused by blockage of dopamine receptors in the brain's basal ganglia) associated with Geodon. The same note revealed Current Geodon dosing was reviewed. The pharmacist noted that 40 mg twice daily is the recommended dose for [their]age. The pharmacist also reviewed that dyskinesia could become more noticeable during dose reduction or discontinuation, including withdrawal-emergent dyskinesia with abnormal facial movements. The same note revealed that nursing will request the nurse practitioner (CRNP) to decrease Geodon to 40 mg twice daily and that the team will continue to monitor [resident] for now. A review of Resident 42's physician's order dated April 29, 2026, revealed an order of Geodon 40 mg twice daily for bipolar disorder. A review of Resident 42's physician's order dated May 6, 2026, revealed an order of Ativan 0.5 mg three times a day for anxiety. A review of Resident 42's clinical record, Behavior Management Committee Summary, dated May 26, 2026, revealed, [Resident name] continues to have repetitive mouth and facial movements. The same note revealed The team recommended decreasing Geodon to 40 mg twice daily due to [their] dose being slightly higher than what is recommended for [their] age group. The team recommended reducing [NAME] to 40 mg twice daily, and the CRNP agreed with these recommendations. The note also indicated The team will continue to monitor [resident name] for now and is not recommending any additional changes at this time. A review of Resident 42's clinical records miscellaneous revealed that there were no Behavior Management Committee Summary notes for the months of June and July 2026. A review of Resident 42's AIMS (A test used to assess and monitor involuntary movements) completed by the MDS nurse (A nurse who specializes in managing the Minimum Data Set and clinical reimbursement in long-term care facilities) on June 30, 2026, revealed the resident's oral and facial movements were none, normal. An observation of Resident 42 conducted on August 4, 2026, at 10:00 a.m., revealed the resident was sitting in the dining room, and movement of the mouth/jaw was observed. An observation of Resident 42 conducted on August 5, 2026, at 9:30 a.m., in the presence of licensed nurse Employee E4 and unlicensed Employee E5 revealed resident was sitting in the dining room with continuous movement of the mouth and jaw. An interview with Employee E3 conducted on August 5, 2026, at 9:30 a.m., revealed that the resident's movement of the mouth/face had been present since they were admitted to the facility around two years ago. An interview with Employee E4 conducted on August 5, 2026, at 9:35 a.m., revealed that the resident's involuntary movement of the mouth was their normal and only stops when they sleep. Employee E3 and E4 confirmed that they were Resident 42's full-time morning caregivers. An observation of Resident 42 conducted on August 6, 2026, at 1:00 p.m., revealed resident was in the recreation room, participating in activity. The resident was observed with movement of the mouth/jaw. An observation of Resident 42 was conducted on August 7, 2026, at 9:30 a.m.; the resident was observed in their room, sitting on their wheelchair with movement of the mouth/jaw.An interview conducted with Employee E3 on August 7, 2026, at 10:30 a.m., revealed the resident's involuntary movement of the mouth varies, sometimes it's better, sometimes it's worse, usually after care was provided or when they get tired. There was no documentation of the repetitive movements of the Resident mouth /jaw on August 4, 5, and 6, 2026. An interview with the DON (Director of Nursing) was conducted on August 7, 2026, at 10:00 a.m. The DON reported that a monthly note, Behavior Management Summary, documents the resident's behaviors, medication changes, and side effects. The DON confirmed that after May 26, 2026, there were no monthly notes on the resident's clinical records. At 11:45 a.m., the DON provided a Behavior Management Summary, for July 2026, unsigned, and it was not found in the resident's clinical records review. The above was conveyed to the Director of Nursing on August 7, 2026, at 11:45 a.m. The facility failed to ensure Resident 42 was closely and consistently monitored after psychotropic side effects were observed and the psychotropic medication dosage/duration order was changed. A review of Resident 79's physician order revealed the following orders dated May 26, 2026, Xanax 0.5 mg one tablet once daily for anxiety; and Xanax 0.5 mg every four hours as needed for anxiety for three months. A review of Resident 79's June, July, and August Medication Administration Record (MAR) revealed that from June 17, 2026, until August 7, 2026, Resident 42 was administered with as needed Xanax on the following dates: June 17, 24, 27, 30 x 2, July 1, 11, 12, 16, 20, 22, 23, 27, 29, 30, and August 2,3, and 6, 2026. There was no documentation from the physician indicating the reason for the need to extended use of the as-needed Xanax for more than 14 days. An interview with the DON conducted on August 7, 2026, at 10:00 a.m., confirmed that there was no documented rationale from the physician regarding the extended use of the as-needed Xanax for Resident 79. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa Code 211.5(f) Clinical Records

Based on observations, review of the facility's policy and clinical records, and staff interviews, it was determined that the facility failed to revise a care plan for psychotropic medication side effects for one of five residents reviewed (Resident 42). Findings: A review of the facility's policy titled Psychotropic Medication/Behavioral Management Policy, last reviewed in March 2026, revealed Revise the care plan as needed. Review the interventions for effectiveness and change as needed. Care plans should include all target behaviors, expressions of distress, non-pharmacological interventions, and desired outcomes. A review of Resident 42's current care plan revealed a care plan for High Risk Medication-potential for side effects, developed on February 14, 2025. Interventions include Monitor for effectiveness of medication; Observe for sign/symptoms or changes in condition and notify physician of any troublesome symptoms or changes in condition. A review of Resident 42's clinical record, Behavior Management Committee Summary, revealed that on April 28, 2026, Staff have noticed newly observed repetitive oral/facial movements, described as opening and closing mouth movements. This appears to be a new finding and may represent dyskinesia (An impairment of voluntary movement resulting in unwanted, uncontrollable, and involuntary muscle movements) or another extrapyramidal side-effect (EPS- drug-induced disorders caused by blockage of dopamine receptors in the brain's basal ganglia) associated with Geodon. A review of Resident 42's clinical record, Behavior Management Committee Summary, dated May 26, 2026, revealed, [Resident name] continues to have repetitive mouth and facial movements. An observation of Resident 42 conducted on August 4, 2026, at 10:00 a.m., revealed the resident was sitting in the dining room, and movement of the mouth/jaw was observed. An observation of Resident 42 conducted on August 5, 2026, at 9:30 a.m., in the presence of licensed nurse Employee E4 and unlicensed Employee E5 revealed resident was sitting in the dining room with continuous movement of the mouth and jaw. An observation of Resident 42 conducted on August 6, 2026, at 1:00 p.m., revealed resident was in the recreation room, participating in activity. The resident was observed with movement of the mouth/jaw. An observation of Resident 42 conducted on August 7, 2026, at 9:30 a.m. revealed the resident was observed in their room, sitting on their wheelchair with involuntary movement of the mouth/jaw. A review of Resident 42's care plan revealed the facility did not revise the care plan after psychotropic side effect behaviors were observed since April 28, 2026. An interview with the Director of Nursing conducted on August 7, 2026, at 10:00 a.m. confirmed that the resident's care plan was not revised after psychotropic medication side effects were observed. The facility failed to ensure Resident 42's care plan was revised after psychotropic medication side effects were observed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa Code 211.5(f) Clinical Records

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to follow physician's orders for one of 20 residents reviewed (Resident 6.) Findings include: Review of facility policy, Bowel Management Program, dated November 2017, revealed On day three, if no bowel movement occurs, give [MEDICATION(S)] in the evening. If resident refuses, document bowel assessment and continue to day four interventions. On day four, if no bowel movement occurs, insert a [MEDICATION(S)] Suppository rectally in the morning. Review of Resident 6's clinical record revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident 6's care plan identified the resident as at risk for constipation with interventions added on December 18, 2017 to follow the bowel protocol and give medications as ordered. Review of Resident 6's physician's orders revealed an order dated December 18, 2017 for milk of magnesia ([MEDICATION(S)]) 30 milliliters (ml) to be given orally as needed for constipation (per protocol). Further review of Resident 6's physician's orders revealed an order dated February 7, 2018 for [MEDICATION(S)] Suppository 10 milligrams (mg) rectally as needed for constipation (per protocol). Review of Resident 6's July 2021 bowel records revealed that on July 26, 2021, it had been three days since the resident had last had a bowel movement. Review of Resident 6's July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 6's progress notes revealed a nurse's note dated July 26, 2021 at 2:24 p.m., which stated, When rechecking the bowel protocol, I realized that resident was given a suppository, but it had only been three days since [resident's] last bowel movement. Per the policy, suppositories are to be given after four days with no bowel movement. Interview with the Director of Nursing on September 10, 2021 at 1:57 p.m. confirmed that the facility failed to follow physician's orders for bowel protocol for Resident 6. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services 28 Pa. code 211.10(c) Resident care policies

Based on clinical record review and staff interview it was determined the facility failed to develop interventions to prevent pressure ulcers and follow a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Findings Include: Review of Resident diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 44's Admission Minimum Data Set (periodic assessment to determine residents needs) dated April 29, 2021 revealed the resident required extensive assist of two staff member for bed mobility. Review of resident 44's Braden Scale for Predicting Pressure Ulcer Risk Assessment, dated May 20, 2021 determined the resident was at risk for developing pressure ulcers. Review of Resident 44's progress notes revealed a nursing entry on June 1, 2021 at 3:43 p.m. stating Upon entering room unstageable pressure injury was noted of (Resident 44's) right heel. Area cleansed with NSS (Normal saline Solution- sterile mixture of salt and water), measured and noted to be 2.4 cm (centimeters) x 2.4 cm, and border foam (bandage with a foam pad surrounded by adhesive material) applied. Review of Resident 44's Wound evaluation Flow Sheet, dated June 1, 2021 revealed the resident had a new pressure ulcer to the right heel that was acquired in the facility, was unstageable (obscured full-thickness skin and tissue loss) measuring 2.4 centimeters long and 2.4 centimeters wide with a scant amount of bloody drainage and a wound bed of slough (yellow or cream-colored dead tissue). Review of Resident 44's care plan revealed a care plan for pressure ulcer development dated April 22, 2021 with interventions of Clean linens, Gel cushion, pressure relieving mattress, check fingernails for sharp edges and pay special attention to placement of hands while in bed. There were no interventions developed specifically for the prevention of pressure ulcers to the heel prior to the development of the pressure ulcer on Resdient 44's right heel. Interview with the Director of Nursing on September 10, 2021 at 9:45 a.m. confirmed there were no interventions developed for Resident 44 to prevent pressure ulcers to the heels. A review of Resident 48's face sheet revealed that the resident was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 48's Minimum Data Set (MDS- An assessment tool used to facilitate the management of care) dated July 30, 2021, revealed that the resident required extensive assistance with two people assistance with bed mobility. A review of the Braden Risk assessment (A tool used to determine risk factors for pressure sore development) dated July 23, 2021, revealed that Resident 48 was at risk for developing pressure ulcer. A review of the progress notes dated August 9, 2021, at 12:40 p.m. revealed that the Nurse Practitioner ordered to apply skin prep to the Resident 48's left heel two times a day until healed. Records revealed that the resident was observed with an intact blister (water) with a measurement of 1.1 x 0.7 to the left heel, the responsible party was notified. A review of the Wound Evaluation Flow Sheet dated August 12, 2021, revealed a blister to the left heel, with a measurement of 1.0 x 1.0 cms., area was off loaded, and wound treatment was changed. A review of the written physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the August 2021, Treatment Administration Record (TAR) revealed that the wound order (border foam) to the left heel was not transcribed to the TAR. Additional review revealed an order that the dressing to the left heel ulcer is clean, dry, and intact, which was signed by the staff every shift. An interview with licensed nurse Employee E3 on September 9, 2021, revealed that a dressing was applied on resident's left heel as evidenced by the nurse's signature on August 2021 TAR indicating that left heel dressing was clean, dry and intact, but the nurse was unable to indicate when and what kind of dressing was applied to Resident 48's left heel ulcer. The facility failed to follow the physician's wound care order to Resident 48's left heel blister. 8 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(d)(3)(5) Nursing Services

Based on a review of clinical record, review of facility documentation and staff interview, it was determined that the facility failed to ensure that care plans were developed and updated to reflect the needs of two of 23 residents reviewed (Resident CL1 and Resident D5). Findings include: Review of Resident CL1's [DIAGNOSES REDACTED]. Review of Resident CL1's clinical record revealed that the resident was admitted to the facility on [DATE] after receiving surgical repair of a hip (femur) fracture (broken bone) sustained in a fall at home. Review of Resident CL1's Nurse's Record dated October 4, 2016 revealed that Resident CL1 sustained a fall out of bed. Review of facility documentation related to Resident CL1's October 4, 2016 fall revealed new interventions including re-educating the resident on the use of the call bell system and a new mattress was to be put into place to prevent further falls from bed. Review of Resident CL1's fall care plan revealed that the above interventions were not initiated and no new interventions were put into place to prevent further falls. Further review of Resident CL1's falls care plan revealed that a falls care plan was originated on September 20, 2016 when the resident was first admitted to the facility and it was not until October 26, 2016 that a care plan for risk of falls was developed. Review of Resident D5's [DIAGNOSES REDACTED]. Review of Resident D5's Admission Minimum Data Set (MDS - periodic assessment of resident needs) dated November 22, 2016, Section G0110, Activities of Daily Living, B - Transfer and I - Toilet Use the resident was coded 3-3 (extensive assistance of two persons). Review of Resident D5's Activities of Daily Living (ADL) care plan dated December 7, 2016 revealed that Resident D5 required the assistance of one person for transfers and toileting and updated with the resident requiring extensive assistance of two persons as indicated on the MDS completed on November 22, 2016. The facility failed to ensure that care plans were developed or updated to reflect the needs of residents. 28 Pa. Code 211.10(a) Resident Care Policies Previously cited 12/11/15 28 Pa. Code 211.10(d) Resident Care Policies Previously cited 12/11/15 28 Pa. Code 211.5(f) Clinical Records Previously cited 12/11/15, 6/20/16 28 Pa. Code 211.11(d) Resident Care Plan Previously cited 12/11/15 28 Pa. Code 211.12(c) Nursing Services Previously cited 12/11/15, 6/20/16 28 Pa. Code 211.12(d)(3) Nursing Services Previously cited 12/11/15 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 12/11/15, 6/20/15

Based on facility policy, observation, clinical record review, facility documentation and staff interviews, it was determined that the facility failed to follow physician's orders [REDACTED]. [REDACTED]. Findings include: Review of the facility's Diabetic Management Protocol, revised May 2013, revealed that blood glucose levels should be performed on residents as close as possible to 0600 (6:00 a.m.), 11:00 (11:00 a.m.), 16:00 (4:00 p.m.) and 20:00 (8:00 p.m.) or at other times specifically ordered by the physician. Review of facility Bowel Management Program, revised date February 2011, indicated that each resident was to be assessed and provided with appropriate treatment and services to achieve regular bowel elimination, avoid constipation, promote psychological well being and dignity, and prevent skin irritation and breakdown. Procedure Step 2 indicated that on day one, if no bowel movement occurred, give prune juice of laxative mix at bedtime and increase fluids as appropriate. Step 3 indicated that on day two, if no bowel movement occurred, give laxative at bedtime. Step 4, on day three indicated if no bowel movement occurred, insert a suppository rectally. Review of Resident D10's [DIAGNOSES REDACTED]. Review of Resident D10's October 2016 physician' s orders revealed orders for Accuchecks (blood sugar level measurements) to be obtained before meals and at bedtime; [MEDICATION NAME] Insulin (medication used in the treatment of [REDACTED]. Review of Resident D10's October 2016 Medication Administration Record [REDACTED]. Further review of the October 2016 MAR indicated [REDACTED]. Further review of Resident D10's October 2016 MAR indicated [REDACTED]. Further review of this MAR indicated [REDACTED]. Review of Resident D10's physician's orders [REDACTED]. Review of Resident D10' s November 2016 MAR indicated [REDACTED]. Further review of the November 2016 MAR indicated [REDACTED]. Review of Resident D10's December 2016 physician's orders [REDACTED]. sugar level was less than 110 mg/dl. Review of Resident D10's December 2016 MAR indicated [REDACTED]. Further Review of Resident D10's December 2016 MAR indicated [REDACTED]. Observation of Resident D10's medication pass on December 7, 2016 at 8:40 a.m. revealed that Resident D10 received [MEDICATION NAME] Insulin 35 units and [MEDICATION NAME] Insulin 12 units at 8:40 a.m. and Resident D10 received breakfast at 8:45 a.m. Review of Resident D10's MAR indicated [REDACTED]. The facility failed to follow the physician's orders [REDACTED]. Review of Resident G11's physician order, dated April 13, 2015 revealed an order for [REDACTED]. Review of Resident G11's medication administration records for October and November 2016, accompanied by licensed Employee E4, on December 7, 2016 at approximately 2:00 p.m. confirmed that [MEDICATION NAME] 50 milligrams was administered to the resident. Review of Resident G13's clinical record revealed a [DIAGNOSES REDACTED]. Review of the current physician orders [REDACTED]. The nurse confirmed that she should have administered the honey liquids to the resident during the medication pass. Review of Resident G15's physician orders [REDACTED]. Employee E3 confirmed that staff should have followed the bowel protocol and administered MOM as a first intervention. 28 Pa. Code 211.5(f) Clinical Records Previously cited 12/11/15, 6/20/16 28 Pa. Code 211.11(d) Resident Care Plan Previously cited 12/11/15 28 Pa. Code 211.12(c) Nursing Services Previously cited 12/11/15, 6/20/16 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 12/11/15, 6/20/15

Based on clinical record review and staff interview, it was determined that the facility failed to administered an anti- anxiety medication within the parameters ordered by the physcian for one out of 21 residents reviewed (Resident G4). Findings include: Review of Resident G4's [DIAGNOSES REDACTED]. Review of Resident G4's August 2016 physician's orders [REDACTED]. Review of Resident G4's August 2016 Medication Administration Record [REDACTED]. Further review of Resident G4's August 2016 MAR indicated [REDACTED]. Review of Resident G4's September 2016 and November 2016 physician's orders [REDACTED]. Review of Resident G4's September 2016 MAR indicated [REDACTED]. Review of Resident G4's November 2016 MAR indicated [REDACTED]. This above information was conveyed to the Director of Nursing on December 7, 2016 at approximately 11:55 a.m. The facility failed to administered the anti- anxiety medication within the parameters ordered by the physician for Resident G4. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services Previously cited 12/11/15, 6/20/16

Based on observation and staff interview, it was determined that the facility failed to maintain a temperature and cleaning log for the [MEDICATION NAME]. Findings include: Observations conducted during the environmental tour December 8, 2016 at approximately 12:20 p.m. of the rehabilitation department in the accompanied of therapy staff, Employee E5, confirmed that there was a cloudiness and a buildup of debris in the [MEDICATION NAME] and no evidence of a cleaning or maintenance log for the [MEDICATION NAME]. Further, the facility failed to provide a daily temperature log for the [MEDICATION NAME] and Employee E5 indicated that nursing was to be checking and recording temperatures. 28 Pa. Code: 207.2(a) Administrator's responsibility Previously cited 12/11/2015

Based on clinical record review and staff interview, it was determined that the facility failed to assure that the resident assessment accurately reflected the resident's current status in the areas of falls, cognition, mood and pain for three of 20 residents reviewed. (Resident E6, F6, I5) Findings include: Review of Resident E6's significant change Minimum Data Set (MDS - assessment of resident care needs and status) dated April 18, 2016, revealed that the resident was readmitted to the facility on [DATE]. Review of section J1800 title Any Falls Since Admission or Prior Assessment which ever is more recent indicated that the resident had a fall. Section J1900 title Number of Falls since Admission or Prior Assessment indicated that the resident sustained [REDACTED]. Review of Resident E6's Resident Incident/Accident Record revealed that the resident did not have a fall since readmission. Interview with licensed Employee E3 on June 17, 2016, at 10:05 a.m. confirmed that the MDS assessment was coded inaccurately for section J1800 and J1900. Review of Resident F6 quarterly Minimum Data Set (MDS- periodic assessment of resident needs), dated March 3, 2016 revealed under section J0200 Should Pain Assessment Interview be Conducted? , this section was coded as yes, Sections J0300 through J0600, which are the questions for the pain interview, were coded with dashes (-) indicating they were not completed. Interview with licensed nursing Employee E3 on June 17, 2016 at 10:00 a.m. confirmed that the pain interview was not conducted for this assessment. Further review of the resident quarterly MDS of March 3, 2016 revealed under section G0400 titled Function Limitation in Range in Motion revealed the resident was coded as having upper and lower impairment on both side of the body. Review of Resident F6 quarterly MDS dated [DATE] revealed section G0400 was coded as having upper and lower impairment on only one side of the body. Interview with licensed nursing Employee E3 on June 20, 2016 at 9:30 a.m. confirmed that the range of motion was coded incorrectly on the May 26, 2016 quarterly assessment. Review of Resident I5's Admission Minimum Data Set (MDS- periodic assessment of resident needs), dated May 6, 2015, revealed that the resident was sometimes understood by others and sometimes understands others. Further review indicated that Section C0100 title Should Brief Interview for Mental Status be Conducted? was coded with a dash (no answer given) for completing the cognition interview with the resident and all answers for that section were answered with a dash, including the summary score section which should be marked with a 99 if the resident was unable to complete the interview. Additional review of the Resident I5 ' s assessment revealed that Section D0100 title Should Resident Mood Interview be Conducted? was also answered with all dashes (-). An interview was conducted with licensed Employee E3 on June 16, 2016 at approximately 10:08 a.m. revealed that the MDS was not completely correctly. 483.20 (g) Accuracy of Assessment Previously cited: 12/11/15 28 Pa. Code: 211.5 (f) Clinical records. Previously cited: 12/11/15 28 Pa. Code: 211.12 (c)(d)(1)(5) Nursing services. Previously cited: 12/11/15

Based on clinical record review and staff interview, it was determined that the facility failed to develop or revise a plan of care addressing an identified resident need for three out of 20 residents reviewed. (Resident B10, F5, and I5). Findings include: Review of Resident B10's current care plan included a care plan for anticoagulant medication (medicine used to prevent blood clots) related to aspirin. Review of physician's orders [REDACTED]. Interview with licensed Employee E3 on June 17, 2016, at 10:05 a.m. confirmed that the care plan should have been updated. Review of Resident F5's clinical record revealed that Resident F5 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident R5's weekly wound assessments revealed that the resident developed an unstageable pressure ulcer on the coccyx that measured 3 centimeter long and 0.8 centimeters wide. Review of Resident F5's admission care plan, dated April 19, 2016 revealed there were no interventions in place at the time of admission for further prevention of the development of pressure ulcers. Interview with the Director of Nursing on June 17, 2016 at 1:00 p.m. confirmed there was no care plan in place to prevent pressure ulcers on admission to the facility. Review of Resident I5 ' s clinical record revealed nursing notes that the resident has been refusing medications at times. Further review of the Medication Administration Records (MAR) for the month of May, 2016, the resident refused multiple medications for 16 days out of 31 days. Further review revealed that in June 2016 the resident had refused multiple medications nine days out of 16 days. Further review of Resident I5 ' s clinical record revealed that a care plan was not developed to address the medication refusals. An interview was conducted with the Director of Nursing on June 16, 2016 at approximately 9:15 a.m. confirmed that the care plan did not address the medication refusals. 279 483.20(k) Comprehensive Care Plans Previously cited: 12/11/15 28 PA Code 211.5(f) Clinical records Previously cited: 12/11/15 28 PA Code 211.11(d) Resident care plan Previously cited: 12/11/15 28 PA Code 211.12(d)(1)(3)(5) Nursing services Previously cited: 12/11/15

Based on review of the clinical record, observation and staff interview, it was determined that the facility failed ensure that interventions to prevent falls were implemented during resident transfer for one of 22 residents reviewed, which resulted in actual harm to Resident E4, and failed to secure hazardous chemicals on one out of two nursing units (1st and 2nd Floor) Findings include: Review of the facility policy entitled Transfer/Lift Policy dated 12/13 (no year listed)revealed that the criteria for afull body lift device should be used if the resident was unable to follow directions and cooperate and was non weight bearing. The type of resident transfer will be listed on the care plan and care card. Review of Resident E4's [DIAGNOSES REDACTED]. Review of Resident E4's quarterly MDS (a periodic assessment of the resident's care needs) dated August 18, 2015 revealed that the resident required the extensive assistance of two for transfers. The BIMS (brief interview for mental status) revealed that the resident scored a 7 or was severely cognitively impaired (thinking ability). Review of the resident's fall risk assessment dated [DATE] revealed that the resident was at high risk for falls. Review of the care plan revealed that the resident was to be transferred with a mechanical lift (added to the care plan 7/21/2014). In addition, the care plan also stated that the resident was a one person assist for toileting, hygiene, bathing and dressing (added to the care plan 8/28/2013). Review of fall assement documentation dated September 2, 2015 revealed that during evening care the resident started to sit down before the wheelchair was underneath of the resident and the Resident E4 sat on the bathroom floor. Interview with the Director of Nursing on December 11, 2015 at 10:00 a.m. revealed that the facility uses a one person transfer for their lift as outlined in the lift handbook. The resident's care plan revealed that the resident was a lift for transfers. The nursing assistant was transferring the resident at a time when the resident was tired and should have utilized the lift as directed in the care plan. Review of September 2015 physician's orders revealed that a physician's order was obtained on September 2, 2015 for the resident to be transferred to the hospital for evaluation and treatment after the fall incident. Review of nursing notes dated September 7, 2015 revealed that the resident was readmitted to the facility with a [DIAGNOSES REDACTED]. The facility failed to follow the resident's care plan which directed the nursing staff to transfer the resident with the use of a mechanical lift during transfers which resulted in actual harm to Resident E4, sustaining a fracture of the right femur. During the initial tour of the unit on December 8, 2015 at approximately 12:15 p.m. a bottle of non acetone nail polish remover and a can of Rave hair spray was observed in an unsecured cabinet in the Gingko (2nd floor) hallway. This was brought to the attention of the unit manager, Employee E3 who confirmed that there were residents with cognitive impairment and poor safety awareness on the unit who should not have access to these items. F323 483.25 (H) Accidents and Supervision Previously cited 11/13/2014 28 PA Code 211.5(f) Clinical records Previously cited 1/20/2015 28 PA Code 211.11(d) Resident care plan Previously cited 1/20/2015 28 PA Code 211.12(d)(1)(3)(5) Nursing services Previously cited 1/20/2015

Based on review of manufacture's recommendation, observations and interviews with staff, it was determined that the facility failed to ensure that all dietary staff wore hairnets in the kitchen and that nutritional supplements were discarded after their expiration shelve life period. Findings include: Observation of the dietary department during the initial tour on December 8, 2015 at approximately 12:00 noon, accompanied by Director of Dining Services and on re-visits to the dietary department on all days of the survey was observed in the main kitchen area without a hairnet. Interview with the Director of Dining Services at the time of observation confirmed that hairnets were worn in the kitchen only at the production line. Interview with the Director of Dining Services on December 9, 2015 at 9:00 a.m. confirmed that she follows the FDA Food Code. Interview with a certified food protection professional, Employee E10 on December 11, 2015 at approximately 10:30 a.m., confirmed that the dietary department followed the current FDA Food Code, 2013 Employee E10 indicated during interview that dietary staff must wear hair restraints (e.g., hairnet, hat and/or beard restraint) to prevent their hair from contacting exposed food. Further observations made during the initial tour of the dietary department on December 8, 2015 at approximately 12:30 p.m., accompanied by the Director of Dining Services revealed a tray dated November 24, 2015 containing of Mighty Shakes (Hormel) 4 fluid ounce cartons (5 chocolate flavored and 5 vanilla flavored). Director of Dining Services when asked stated the Mighty Shakes had a shelf life of 7 days. Manufacture's recommendation for Hormel Health Labs last updated November 5, 2014 revealed Mighty Shakes if kept frozen have a shelf life of 15 months and after being refrigerated have a shelf life of 14 days, thawed. Interview with Director of Dining Services at the time of observation confirmed the Mighty Shakes should have been discarded. 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: 211.6 (f) Dietary services. Previously cited 1/20/15

Based on observations and staff interviews, it was determined that the facility failed to assure that staff knocked on resident doors, appropriately labeled clothing and provided for a positive dining experience to assure resident dignity for nine out of 29 residents reviewed. (Resident B12, B15, C6, D7, D11, F4, F7, F9 and F13) Findings include: During a medication pass observation on December 8, 2015 at approximately 3:30 p.m., licensed nursing staff, Employee E4 failed to knock on resident doors and wait to be invited in while administering medications to Resident F4, F7 and F13. An observation made on December 8, 2015 at 3:15 p.m. revealed that Resident F9 was seated in a wheelchair in the communal lounge with slipper socks on and his feet partially raised. His socks had labels attached to each toe with his name visible to other residents and visitors. During a medication pass observation on December 9, 2015 at approximately 11:00 a.m., a licensed nurse, Employee E5 failed to knock on resident doors and wait to be invited in while administering medications to Residents C6 and D11. During a medication pass observation on December 10, 2015 at approximately 11:15 a.m., a licensed nurse, Employee E6 failed to knock on resident doors and wait to be invited in while administering medications to Residents B12 and B15. During an individual interview on December 11, 2015 at 1:30 p.m. with Resident D7 indicated that she doesn't like receiving medications while eating meals in the dining room. 28 Pa. Code: 201.18 (b)(2)(e)(1) Management. 28 Pa. Code: 201.29 (j) Resident rights. 28 Pa. Code: 211.10 (a) Resident care policies.

Based on a review of the facility policy, clinical records and staff interview, it was determined that the facility failed to follow bowel protocol for a new admission to the facility for one resident (Resident CL3) and physician's orders for annual [MEDICAL CONDITION] (TB) tests for 11 of 22 residents reviewed (Resident A8, A14, B1, B9, B11, B14, E1, E4, E11, F4 and G9). Findings include: Review of the facility policy entitled Bowel Management Program protocol for new admission a bowel history is to be obtained by the licensed nurse completing the admission assessment and paperwork will note the date of the last bowel movement as documented on the hospital transfer form. The nurse will record this date on the BM chart so the individually ordered bowel protocol may be initiated effective the date of the last bowel movement. Review of Resident CL3 ' s revealed that the date of admission to the facility was August 7, 2015. Further review of the clinical record revealed the discharge record from the hospital stated that the patient has unknown last bowel movement, [MEDICATION NAME] (a stool softener) was given on August 7, 2015. Further review of the clinical record revealed a fax dated August 11, 2015 sent to the physician that Resident CL3 did not have a bowel movement since the date of admission (August 7, 2015) and asked to repeat the facility ' s bowel protocol. There was no documented evidence that Resident CL3's bowel movements were monitored from August 7, 2015 until August 12, 2015. An interview with the Director of Nursing on December 10, 2015 at approximately 3:15 p.m. revealed that the nurse should have initiated the bowel protocol regimen upon admission due to the hospital ' s note stating unknown last bowel movement. Review of the current physician's orders for Residents A8, A14, B1, B9, B11, B14, E1, E4, E11, F4 and G19 revealed a physician order to administer an annual PPD (purified protein derivative-the substance used in an intradermal test for [MEDICATION NAME] skin test). The facility could not provide documentation that the annual PPD was administered for Residents A8, A14, B1, B9, B11, B14, E1, E4, E11, F4 and G19 annually. An interview was conducted with the Administrator on December 10, 2015 at approximately 3:00 p.m. revealed that the facility does not do annual TB tests if the resident has not left the building. Further investigation revealed that the facility was aware of the physician order for [REDACTED]. The facility failed to follow the physician orders for annual TB tests. 28 Pa. Code: 201.18(b)(1) Management Previously cited 01/20/2015 28 Pa. Code: 211.5(f)(h) Clinical records Previously cited 01/20/2015 28 Pa. Code: 211.12(d)(3)(5) Nursing services Previously cited 01/20/2015

Based on observation and staff interviews, it was determined that the facility failed to document the dosage strength of a medication being administered, to identify expired medications and to disposed of outdated medications on two out of two nursing units. (1st and 2nd floor) Findings include: An observation was made on December 8, 2015 at approximately 4:00 p.m. following the medication pass of a multidose vial of flu vaccine in the second floor unit medication refrigerator. The vial was open and dated 10/11/2015. Employee E3 confirmed that this vaccine should be discarded because it was outdated from the open date. During the medication pass on December 8, 2015, the medication nurse, Employee E4 was going to administer to Resident F10 artificial tears eye drops. These eye drops were dated as being opened on October 23, 2015. When questioned about this, Employee E4 agreed that that this eye medication was outdated from the open date and should not be administered. During the medication pass on December 8, 2015 at approximately 4:00 p.m., Employee E4 was going to administer Senna S (a drug used for constipation) to Resident F7. Review of the label did not reveal a strength of the medication being administered. Review of the current physician orders [REDACTED]. A phone interview with the pharmacist, E7 on December 8, 2015 at approximately 4:10 p.m. confirmed that the strength was not included on the label if there is only one strength and because of limited space. CMS requires facility compliance with accepted labeling requirements which at a minimum includes the name of the medication and strength, expiration date, the resident's name, route of administration, instructions for administration and precautions. Although not commonly used there is an additional dose 65 milligrams/10 milligrams of Senna S. The facility failed to assure compliance with medication labeling requirements. An observation was made on December 8, 2015 at 5:25 p.m. of the 1st floor unit medication refrigerator revealed a package of five Hydrocortisone Acetate 25 milligram (medication used to help relief rectal pain) suppositories which had expired May 4, 2015; a package of two Phenadoz 25 milligram (an antihistamine used to treat allergic reactions and to treat or prevent nausea and vomiting from illness or motion sickness) suppositories which had expired August 4, 2015; a package of two Phenergan 25 milligram (an antihistamine used to treat allergic reactions and to treat or prevent nausea and vomiting from illness or motion sickness) suppositories which had expired August 29, 2015; a package of two Phenadoz 25 milligram suppositories which had expired August 30, 2015 and a package of one Phenadoz 25 milligram suppositories which had expire September 26, 2015. Further observation of the medication cabinet revealed a bottle of Artificial Tear Drops for Resident B13. These eye drops were dated as being opened on July 31, 2015. The Artificial Tear Drops should have been discarded after 30 days, once opened. Interview with a licensed nurse Employee E9 at time of the observation confirmed that the expired medication should have been discarded and the bottle of artificial tear drops should have been discarded after the 30 day of being opened. 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 Previously cited 1/20/15

Based on review of clinical record, observations and interviews with staff, it was determined that the facility failed to follow safe infection control practices relating to handwashing during medication pass and meal observations on two of two nursing units (1st and 2nd floor). Findings include: Review of facility's policy entitled, Hand Hygiene date reviewed December, 2007 indicated that the purpose for this policy was that handwashing is required to reduce cross contamination and/or infection from resident to resident and/or from residents to staff. Step IV. Section B Technique for Soap and Water is to wet hands under a moderate stream of water. Apply soap and lather them vigorously for at least 15 to 20 second. (sing the Happy Birthday Song, twice). Hands are rinsed well and dried. A paper towel is used to dry the hands; use the towel to turn off the faucet. Soap and water hand washing must be used before and after instilling any eye medication. Further review of the facility's policy entitled, Infection Control date revised December, 2007, Section IV. Resident Care Guidelines Section C states that :wash your hands or use a hand sanitizer before assisting a resident to eat. If you are assisting more than one resident to eat, use a hand sanitizer between each resident. During the medication pass observation on December 8, 2015 at approximately 3:40 p.m. Employee E4, the licensed medication nurse completed a glucometer test to determine a blood glucose value (blood sugar) on Resident F13. Employee E4 removed her gloves and proceeded to wash her hands with soap and water. This hand hygiene lasted 7 seconds; the recommended CDC (Center for Disease Control) time for hand washing is 15 to 20 seconds. Employee E4 placed eye drops in Resident F10's eyes during the medication pass at approximately 4:15 p.m. and proceeded to wash her hands for eight seconds rather than the recommended 15-20 seconds. During an observation of a medication pass on December 9, 2015 at 11:00 a.m. a licensed nurse Employee E5, washed hands for five seconds and then turned water faucet off without using a paper towel before administering a topical medication to Resident D11's lower gums. During an observation of a medication pass on December 10, 2015 at 11:30 a.m. a licensed nurse Employee E6, did not wash hand prior to administering eye drops or after administering eye drops to Resident B13's. During an observation of the 1st floor dining room on December 9, 2015 at 12:00 p.m. two feeding assistants did not wash their hands before sitting down with residents and proceeded to feed them. During a meal time observation on December 8, 2015 at approximately 5:15 p.m. until 6:00 p.m. residents were handed a disposable wash cloth to wash their hands. Each resident (approximately 28 residents) washed their hands and laid the disposable wash cloth on the table at their place setting where the disposable wash cloth remained during the entire dinner meal. 483.65 F441 Infection Control Previously cited 1/20/15 28 Pa. Code: 211.10 (d) Resident care policies. Previously cited 1/20/15 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services. Previously cited 1/20/15

Based on review of facility policy and procedure, clinical record review, and staff interview, it was determined that facility failed to conducted interview with staff and/or re-educate nursing staff to ensure that a complete investigation was conducted for incidences of bruises of unknown origin for three of 22 residents reviewed (Resident ' s A14, E1, and E10). Findings include: Review of the facility policy and procedure titled instructions for completion of skin incident/injury report form an incident report is completed by writer the individual observing an event which caused an injury or by the individual discovering the injury. If an injury has an unknown cause and warrants further investigation a statement must be written by the licensed nurse and assigned caregiver of the current and preceding three shifts. Further review of the facility policy stated that if problems were identified during the nurse ' s investigation, immediate corrective action must be taken. The licensed nurse must review safety and accident prevention with the involved team member if indicated. Review of the clinical record for Resident A14 revealed a nursing note dated August 16, 2015 which noted that a bruise was identified on the resident's left forearm an area of bruising measuring 9 cm (centimeters) by 2 cm area and a right inner wrist bruise measuring 8 cm by 6 cm. Review of the facility's report regarding this incident revealed the following statement: When nursing assistant giving evening care the resident got her left forearm caught in the mechanical lift sling and the right arm got stuck in the arm rail of lift. There was no documented evidence that the staff member was re-educated in using the lift and ensuring the residents safety in future transfers. Review of the Resident E1's annual assessment MDS (a periodic assessment of resident care needs) dated August 11, 2015 revealed the resident's BIMS (brief interview for mental status) with a score of 10 which indicated moderate cognitive impairment (thinking/reasoning ability). Review of nursing notes dated March 21, 2015 revealed that staff identified a bruise on the resident's right forearm measuring 3.6 centimeters by 2.1 centimeters. Review of the facility documentation of the investigation failed to reveal that interviews with caregivers for three preceding shifts were completed as outlined in the facility policy. Review of the nursing notes dated October 6, 2015 revealed a bruise on the right forearm measuring 7.4 centimeters by 1 centimeter. Review of the facility investigation documentation did not include interviews with caregivers from three previous shifts to try to determine how the resident sustained [REDACTED]. Review of the clinical record for Resident E10 revealed a nursing note for December 1, 2015 a bruise on the left great toe measuring 2 cm (centimeters) by 2.8 cm. Review of the facility's investigation report into this incident revealed that s the cause was as follows: transfers declining, recent Arjo lift- self propels wheelchair around unit- resident stated she could have bumped it. Review of the facility investigation documentation did not include interviews with caregivers from three previous shifts to try to determine how the resident sustained [REDACTED]. An interview was conducted on December 9, 2015 with the Nursing Home Administrator at approximately 10:05 a.m. revealed that the facility did not feel that the investigation needed to be investigated further. 28 Pa. Code: 201.18 (b)(1)(2)(e)(1) Management 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing 28 Pa. Code 201.29 (c) Residents rights

Based on observations on the second floor nursing unit, it was determined that the facility failed to maintain the environment in a sanitary manner for one out of two units. (2nd floor) Findings include: An observation during the initial tour of the facility, on December 8, 2015 at approximately 12:15 p.m. revealed carpeting around the second floor dining room and resident lounge was stained and soiled. Observations at that time made in the resident spa/bathing area revealed wall paper pealed from the wall measuring approximately two feet by four feet, two bed pillows stored on a resident wheelchair, a commode bucket on the shower chair and bucket stored on the floor containing a scrub brush and thermometer. Employee E3, the unit manager accompanied the surveyor and observed these findings during the tour of the unit. 28 Pa. Code: 207.2 Administrator ' s responsibility

Based on clinical record review and staff interview, it was determined that the facility failed to assure that the resident assessment accurately reflected the resident's current status in the area of pressure ulcer (s) for one of 22 residents reviewed (Resident B9). Findings include: Long Term Care Facilities are to follow the Long Term Care Resident Assessment Instrument User's Manual, Version 3.0 Under Section M Skin Conditions requires coding under M0210. Unhealed Pressure Ulcers; M0300. Current Number of Unhealed Pressure Ulcers at each stage; M0610. Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers (identify the pressure ulcer with the largest surface area (length x width). Coding instructions is to use #1. (yes), if resident had any pressure ulcer (Stage 1, 2, 3, 4 or unstageable) in the 7-day look-back period. Proceed to current number of unhealed pressure ulcers at each stage and identify the dimensions of the pressure ulcer with the largest surface area. Identify all Stage IV pressure ulcer (s) currently present. Review of Resident B9's clinical record revealed a wound center consultation sheet dated February 25, 2015 indicated a healing Stage IV ((full thickness tissue loss with exposed bone, tendon or muscle.) Slough (separation of dead tissue from living tissue, yellow, tan, grey, green or brown) or eschar (dry scab, tan, brown or black in wound bed; dead tissue, black in color in wound bed) may be present on some parts of the wound bed.) sacral pressure ulcer, measuring 4 centimeters by 2.3 centimeters by 2 centimeters with 0.7 centimeters of undermining (refers to wound being open underneath the skin edges so that the pressure ulcer is larger at its base than at the skin surface). Review of physician's progress notes dated April 11 and April 30, 2015 revealed documented evidence of a sacral/coccyx ulcer, Stage IV. Review of Resident B9's annual comprehensive assessment dated [DATE], revealed the resident was not coded under M0210 titled Unhealed Pressure Ulcer. Section M0300 title Current Number of Unhealed Pressure Ulcers at Each Stage and Section M0610 title Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar were both left blank. Interview on December 11, 2015 at 1:45 p.m. with licensed staff, Employee E8, confirmed that the assessment for Resident B9 was not a pressure ulcer. Interview with Administrator and Director of Nursing on December 11, 2015 at approximately 4:30 p.m. confirmed the comprehensive assessment was not coded correctly for pressure ulcers. 28 Pa. Code: 211.5 (f) Clinical records. Previously cited 1/20/15 28 Pa. Code: 211.12 (c)(d)(1)(5) Nursing services. Previously cited 1/20/15

Based on clinical record review and staff interview, it was determined that the facility failed to assure that the resident assessment accurately reflected the resident's current status in the areas of pressure ulcer (s) for one of twenty-two residents reviewed (Resident B9). Findings include: Long Term Care Facilities are to follow the Long Term Care Resident Assessment Instrument User's Manual, Version 3.0 Under Section M Skin Conditions requires coding under M0210. Unhealed Pressure Ulcers; M0300. Current Number of Unhealed Pressure Ulcers at each stage; M0610. Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers (identify the pressure ulcer with the largest surface area (length x width). Coding instructions is to use #1. (yes), if resident had any pressure ulcer (Stage 1, 2, 3, 4 or unstageable) in the 7-day look-back period. Proceed to current number of unhealed pressure ulcers at each stage and identify the dimensions of the pressure ulcer with the largest surface area. Identify all Stage IV pressure ulcer (s) currently present. Review of Resident B9's clinical record revealed a physician's progress note dated January 9, 2015 with documented evidence that Resident B9 had a large sacral decubitus ulcer and was being followed by the wound clinic. Review of the wound center consultation sheet dated January 28, 2015 indicated a healing Stage IV pressure ulcer at sacrum, measuring 3.1 centimeters by 1.3 centimeters by 0.9 centimeters with 1.1 centimeters of undermining (refers to wound being open underneath the skin edges so that the pressure ulcer is larger at its base than at the skin surface). Further review of Resident B9's clinical record revealed a wound consultation sheet dated February 25, 2015 indicated a healing Stage IV sacral pressure ulcer, measuring 4 centimeters by 2.3 centimeters by 2 centimeters with 0.7 centimeters of undermining. Review of a physician's progress note dated July 18, 2015 revealed documented evidence that Resident B9 continues to have a Stage IV coccyx(commonly referred to as the tailbone)/sacral ulcer. Review of Resident B9's quarterly assessment dated [DATE] and the quarterly assessment dated [DATE], revealed the resident was not coded under Section M0210 for having an unhealed Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough (separation of dead tissue from living tissue, yellow, tan, gray, green or brown) or eschar (dry scab, tan, brown or black in wound bed; dead tissue, black in color in wound bed) may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer. Further review revealed Section M0300 title Current Number of Unhealed Pressure Ulcer at Each Stage and Section M 0610 Dimensions of Unhealed Stage 3 or 4 Pressure ulcers or Eschar were both left blank. Interview on December 11, 2015 at 1:45 p.m. with licensed staff, Employee E8, confirmed that the assessment for Resident B9 was not a pressure ulcer. Interview with nursing home administrator and director of nursing on December 11, 2015 at approximately 4:30 p.m. confirmed the comprehensive assessment was not coded correctly for pressure ulcers. 483.20 (g) Accuracy of Assessment Previously cited 1/20/15 28 Pa. Code: 211.5 (f) Clinical records. Previously cited 1/20/15 28 Pa. Code: 211.12 (c)(d)(1)(5) Nursing services. Previously cited 1/20/15