Every finding on record at Fellowship Manor

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection for one of 26 sampled residents. (Resident 6)Findings include: Review of the facility policy titled, Emerging and Other Infectious Diseases, last reviewed June 2026, revealed that a gown and gloves were to be worn with any high contact resident care activity which included wound care. Clinical record review revealed that Resident 6 had diagnoses that include type two diabetes mellitus without complications (a chronic condition characterized by one's body being resistant to insulin, or not producing enough of it, causing high blood sugar), and pressure ulcer of left ankle, stage four (a severe, full-thickness wound extending through the skin into underlying muscle, tendon, or bone). Review of Resident 6's care plan revealed that the resident was to receive a protective dressing to the left lateral ankle. During an observation of wound care to Resident 6's left ankle pressure ulcer, on July 8, 2026, at 10:45 a.m., the Registered Nurse (RN 1) performed a dressing change to the resident's wound. RN 1 did not wear a gown during the dressing change. On July 8, 2026, at 1:00 p.m., the Assistant Director of Nursing confirmed that RN 1 did not use appropriate personal protective equipment (PPE) during Resident 6's dressing change. 28 Pa. Code 211.10(d) Resident care policies. 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 provide copies of the written discharge notices to a representative of the Office of the Long-Term Care Ombudsman for three out of three residents who were discharged from the facility. (Residents 108, 120, and 122)Findings include: Clinical record review revealed that Resident 108 was discharged from the facility on May 16, 2026. There was no documented evidence that the facility sent copies of the written discharge notice to a representative of the Office of the State Long-Term Care Ombudsman.Clinical record review revealed that Resident 120 was discharged from the facility on May 24, 2026. There was no documented evidence that the facility sent copies of the written discharge notice to a representative of the Office of the State Long-Term Care Ombudsman.Clinical record review revealed that Resident 122 was discharged from the facility on May 19, 2026. There was no documented evidence that the facility sent copies of the written discharge notice to a representative of the Office of the State Long-Term Care Ombudsman.In an interview on July 8, 2026, at 2:27 p.m., the Administrator confirmed that the written copies of the discharge notices were not sent to the Office of the State Long-Term Care Ombudsman.28 Pa. Code 201.14(a) Responsibility of licensee.

Based on policy review, observation, clinical record review, and resident and staff interview, it was determined that the facility failed determine a resident's capability to self administer their medications for one of one sampled residents. (Resident 77) Findings include: Review of facility policy entitled, Self Administration of Medications and Bedside Storage, last reviewed June 2025, revealed that if a resident indicated a desire to self administer medications, a member of the interdisciplinary team was to conduct a skills assessment form with the resident to determine the resident's ability to self-administer medications. Once the form was completed, the assessment was to be kept in the resident's medical record. Once determined safe to self administer, the physician/provider was to be notified and self-administration status was to be reflected in the resident's EHR (electronic health record). Bedside storage was to be permitted if the medication was able to be kept out of reach of other residents, could be kept in the original container and the nurse was able to verify and document use. Clinical record review revealed that Resident 77 had a diagnosis of end-stage renal disease for which they received hemodialysis. Review of the Minimum Data Set (MDS) assessment, dated March 20, 2025, revealed that Resident 77's cognitive ability was intact. Observations on June 24, 2025, at 10:00 a.m., and on June 25, 2025, at 11:00 a.m., revealed that there were two bottles of Velphoro (a medication used to control phosphorus levels in the blood) unsecured on the bedside table and on top of the dresser in the Resident 77's room. Additionally, there was one bottle of lidocaine spray and two tubes of lidocaine gel (medications used for numbing the skin) observed unsecured on the bedside table and on top of the dresser in Resident 77's room during the observation periods. In an interview on June 24, 2025, at 10:00 a.m., Resident 77 stated that the Lidocaine was to be applied prior to leaving for dialysis. There was no documentation to indicate that the facility had assessed Resident 77 for the ability to self-administer the Velphoro or the Lidocaine gel. There was no security of the medications in her room. In an interview on June 26, 2025, at 8:45 a.m., the Director of Nursing confirmed that Resident 77 was not assessed to self-administer the medications as per the facility policy. 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 residents were free from potential chemical restraints for one of five sampled residents who were ordered psychotropic medications. (Resident 78) Findings include: Clinical record review revealed that Resident 78 had diagnoses that included Alzheimer's disease, dementia and anxiety. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident was cognitively impaired and had been administered an anti-anxiety medication. On June 12, 2025, a physician ordered for staff to administer an anti-anxiety medication, (Ativan), every five hours as needed for agitated behaviors. There was no date in the order that indicated when staff was to stop administering the as needed medication. Review of the Medication Administration Record for June 2025, revealed that staff had administered the Ativan on June 12, 13, 14, 15 and 22, 2025, for a total of five times. There was no documented evidence that the physician had re-evaluated continued use beyond 14 days of the as needed anti-anxiety medication. In an interview on June 25, 2025, at 3:00 p.m., the Assistant Director of Nursing stated that there had been no date added to the order that indicated when staff was to stop administering the anti-anxiety medication. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and review of incident reports it was determined that the facility failed to ensure that staff provided adequate supervision in order to prevent falls for one of nine sampled residents who were at risk for falls. (Resident 78) Findings include: Clinical record review revealed that Resident 78 was admitted on [DATE], and had diagnoses that included Alzheimer's disease, dementia and anxiety. Review of a fall risk evaluation dated February 23, 2025, indicated that he was at a high risk for falls. The Minimum Data Set assessment dated [DATE], indicated that the resident had a memory problem. A review of the care plan revealed that the resident was at risk for falls due to poor safety awareness, impulsivity, a history of falling and confusion. Review of nursing documentation and incident reports revealed that Resident 78 fell nine times between February 23, 2025, through May 9, 2025. He fell five times out of bed and four times out of his wheelchair. Six of the falls were between the hours of 6:00 a.m. and 1:00 p.m., and three of the falls were between the hours of 7:00 p.m. and 12:00 a.m. Nursing documentation dated February 23, 2025, indicated that the resident was nearly falling out of his wheelchair and had been crawling out of bed. On February 26, 2025, March 3, and March 4, 2025, nursing staff documented that the resident was awake all night, confused, was trying to either get out of bed or out of his wheelchair, making frequent attempts to stand on his own, and was not following any kind of direction from staff. Review of an incident report dated March 7, 2025, at 7:15 p.m., revealed that the resident was found on the floor in his room next to his bed. The incident report further indicated that the resident tries to get up and can not on his own. Nursing documentation dated March 18, 2025, at 2:46 a.m., revealed that the resident was restless and making several attempts to get up from his chair. Review of an incident report dated March 18, 2025, at 9:20 a.m., revealed that staff found the resident lying on his back in front of his wheelchair in the hallway. The report further indicated that he was displaying increased restlessness around the time of the incident. Nursing documentation dated March 21, 2025, at 6:28 a.m., revealed that the resident had been awake, anxious and restless all night. He was also making several attempts to get up from his chair to stand unassisted. Review of an incident report dated March 21, 2025, at 1:00 p.m., revealed that the resident was found in the hallway lying on the floor in front of his wheelchair. Review of incident reports dated March 24, 2025, and March 29, 2025, revealed that the resident had two more falls out of his wheelchair. Review of an incident report dated April 6, 2025, revealed that the resident had fallen out of bed. Nursing documentation dated April 23, 2025, revealed that the resident had been sitting on the edge of his bed and attempting to stand up. He was transferred to a chair and continued to attempt to stand up unassisted. Review of an incident report dated April 29, 2025, at 6:33 a.m., revealed that the resident had fallen out of bed. Nursing documentation dated May 5, 2025, revealed that the resident was climbing out of bed. The note further indicated that the resident was not put back to bed as it is unsafe. Review of an incident report dated May 6, 2025, at 11:09 p.m., revealed that the resident had again fallen out of bed. Nursing documentation dated May 8, 2025, at 3:23 a.m., revealed that the resident had been confused and had multiple times attempted to stand up from his chair unassisted. Review of an incident report dated May 9, 2025, at 9:20 a.m., revealed that the resident had again fallen out of bed. There was no documented evidence that the facility had provided adequate supervision at the aforementioned times when the resident was frequently exhibiting behaviors specifically attempts to get out of his bed our wheelchair or to stand unassisted by staff in order to prevent falls. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, review of personnel files, and staff interview, it was determined that the facility failed to initiate an employee criminal background check for one of five sampled newly hired employees. (Employee DE 1) Findings include: Review of the facility policy entitled Prevention from Abuse/Neglect/Involuntary Seclusion and Misappropriation of Resident Property, dated July 2022, revealed that if the facility determined an applicant eligible to be hired, a state police background check would be conducted to reduce the risk of hiring an employee likely to abuse residents. Employee DE 1 had been working at the facility since May 28, 2022. Review of DE1's employee file revealed that the Pennsylvania State Police background check had not been completed until August 12, 2022. In an interview conducted on August 12, 2022, at 9:40 a.m., the Nursing Home Administrator confirmed that DE1's employment screening had not been completed until August 12, 2022. CFR 483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Previously cited 9/24/21 28 Pa.Code 201.14(a)Responsibility of licensee 28 Pa.Code 201.19 Personnel policies and procedures

Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity to one resident on one of two nursing units. (Resident 311) Findings include: Clinical record review revealed that Resident 311 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment, dated September 8, 2021, revealed that the resident had cognitive impairments, and required extensive assistance with activities of daily living, including eating. On September 22, 2021, from 9:07 a.m. through 9:08 a.m., Registered Nurse (RN) 1 was observed standing while feeding the resident. Nurse Aide (NA) 1 was observed standing while feeding the resident from 9:08 a.m. through 9:17 a.m. NA 2 was observed standing while feeding the resident her breakfast from 9:17 a.m. through 9:37 a.m. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure that staff provided adequate assistance during a transfer for one of 24 sampled residents. (Resident 94) Findings include: Clinical record review revealed that Resident 94 had diagnoses that included dementia and arthritis. On March 5, 2021, the physician wrote an order directing two staff members to assist Resident 94 during transfers. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had memory impairment and was totally dependent on two staff for transferring between surfaces. The care plan indicated that two staff members were to assist the resident for transfers between surfaces. Review of facility documentation revealed that on May 12, 2021, Resident 94 was transferred with the assistance of one nurse aide from her chair to her bed. During the transfer Resident 94 bumped her leg on the side of the bed and sustained a skin tear. During an interview on September 23, 2021, at 2:13 p.m., the Director of Nursing confirmed that Resident 94 was transfered to bed by one staff member on May 12, 2021, and that staff should have transferred the resident back to bed according to the physician's order. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate injuries of unknown origin to rule out abuse or neglect for one of 24 sampled residents. (Resident 47) Findings include: Review of the facility policy, Incident Report Policy, dated October 28, 2020, revealed that the facility was to report and thoroughly investigate all instances of bruising including injuries of unknown origin. According to the policy, staff was to ensure that new skin bruises were to be documented on the accident/injury reporting form and an investigation as to how the resident acquired the bruise was to be completed. Clinical record review revealed that Resident 47 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], identified that the resident had no memory impairment and was dependent on staff for activities of daily living. A skin assessment completed on March 30, 2021, revealed that the resident had a purplish yellow bruise located on her right inner thigh and a discolored brown area on her left lateral leg. There was no evidence that the facility completed a thorough investigation into the cause of the injury for Resident 47. In an interview on September 22, 2021, at 2:15 p.m., the Director of Nursing confirmed there was no documentation to support that the facility thoroughly investigated the cause of the injuries of unknown origin for Resident 47 to rule out abuse or neglect. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on clinical record review, resident interview, and observation, it was determined that the facility failed to ensure that a resident had access to their personal belongings for one of 24 sampled residents. (Resident 6) Findings include: Clinical record review revealed that Resident 6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment, dated September 15, 2021, revealed that the resident was alert and oriented, and required extensive assistance from staff for bed mobility and locomotion on the unit (moving from place to place). Review of the current care plan revealed interventions to keep most frequently used and personal items within reach. Observation on September 21, 2021, at 10:06 a.m., revealed that Resident 6 was in bed with her telephone on a table to her left and her greeting cards on a table to her right. There was a sign hanging over her bed to keep her telephone within her reach. During an interview Resident 6 stated she could not reach her items. On September 21, 2021, at 10:54 a.m., the resident was observed out of bed in her wheelchair on the right side of her bed with her telephone on the table to the left side of her bed out of her reach. On September 22, 2021, at 9:47 a.m., Resident 6 was observed in bed with her telephone on the table to her left. The telephone was out of her reach. On September 23, 2021, Resident 6 was observed out of bed in her wheelchair on the right side of her bed with her telephone on the table to the left side of her bed out of her reach. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observation, clinical record review and staff interview, it was determined that the facility failed to provide appropriate services to prevent further decrease in range of motion for two of five sampled residents with limited range of motion. (Resident 82, 162)Findings include: Clinical record review revealed that Resident 162 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated (MONTH) 7, (YEAR), indicated that the resident was cognitively impaired, had functional limitation in range of motion, and required extensive assistance from staff for most activities of daily living. The ongoing care plan dated (MONTH) 1, 2019, revealed that the resident was at risk for skin integrity breakdown related to a decrease in mobility and impaired cognition, and staff would provide a palm guard to the right hand and a therapy carrot to the left hand to prevent further contractures. Review of an occupational therapy discharge summary dated (MONTH) 24, (YEAR), was for staff to provide bilateral hand devices due to increased tightness of the right hand and contracture of the left hand. Observations on (MONTH) 5, (YEAR), from 10:00 a.m. to 2:00 p.m., revealed that the resident was out of bed without his recommended bilateral hand devices applied. Clinical record review revealed that Resident 82 had [DIAGNOSES REDACTED]. The MDS assessment dated (MONTH) 6, 2019, indicated that the resident was cognitively impaired, had functional limitation in range of motion on one side of the upper and lower extremities, and required extensive assistance from staff for most activities of daily living. An Occupational Therapy discharge summary dated on (MONTH) 6, (YEAR), revealed that staff were to apply a left resting hand splint daily. On (MONTH) 14, 2019, the physician ordered left resting hand splint to be applied from 11:00 a.m. through 4:00 p.m. daily.Observations on (MONTH) 6, 2019, from 12:23 p.m. through 1:13 p.m., revealed that the resident was seated in his wheelchair without the left hand splint applied. A second observation on (MONTH) 7, 2019 at 12:12 p.m., revealed that the resident was again seated in his wheelchair without the left hand splint applied. In an interview on (MONTH) 7, 2019 at 12:33 p.m., the Director of Nursing confirmed that staff failed to provide appropriate services for the resident. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, observations, and staff interview it was determine that the facility failed to accomodate resident needs regarding the accessibility to call bells for three of 23 sampled residents. (Residents 33, 37, 55) Findings include: Clinical record review revealed that Resident 33 was admitted to the facility on (MONTH) 11, (YEAR) with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated (MONTH) 2, 2019, revealed that Resident 33 was alert and oriented and required extensive assistance from staff for toileting and bed mobility. On (MONTH) 5, 2019 at 10:07 a.m., Resident 33 was observed attempting to get up from his bed. Resident stated he needed to use the bathroom. The resident further stated my call bell is not near me, and I can't reach it. The care plan dated (MONTH) 9, 2019, identified that the resident was at risk for falls and directed staff to have the resident's items within reach including his call bell. Clinical record review revealed that Resident 37 was admitted to the facility on (MONTH) 31, (YEAR) with [DIAGNOSES REDACTED]. Review of the MDS assessment dated (MONTH) 7, 2019, revealed that Resident 37 was cognitively impaired, was at risk for falls and required extensive assistance from staff with activities of daily living. The care plan dated (MONTH) 27, 2019, identified that the resident was at risk for falls and directed staff to have the resident's items within reach that included his call bell. Observation on (MONTH) 5, 2019 at 9:15 a.m, revealed that the resident was out of bed in his wheelchair with his call bell behind him and on the floor and not within reach. Clinical record review revealed that Resident 55 had [DIAGNOSES REDACTED]. The MDS assessment dated (MONTH) 21, 2019, revealed that Resident 55 was cognitively impaired and required total assistance from staff for transfers. Observation on (MONTH) 6, 2019 at 1:09 p.m., revealed that the resident was out of bed seated in his wheelchair but his call bell was behind him out of reach. In an interview on (MONTH) 7, 2019 at 1:00 p.m, Director of Nursing confirmed that the residents did not have access to their call bells. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure that staff implemented interventions to prevent the potential spread of infection for one of 24 residents sampled. (Resident R87) Findings include: Review of the facility policy Categories of Infection and Transmission Based Precautions (dated February 2, 2017) revealed that a stop sign need(ed) to be placed on the door to alert visitors to report to the nurse prior to entering the resident's room for any resident that is suspected of being infected with an infectious agent. If resident's required droplet precautions, staff and visitor were to wear a mask when within three feet of the resident or when in the resident's room. Clinical record review revealed that Resident R87 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. That day, the physician ordered that staff test the resident's blood for RSV (respiratory syncytial virus, a contagious lung disease) and staff carried out the order. The resident was placed on droplet precautions including the use of mask until the test for RSV was completed. On April 11, 2017, at 1:00 p.m., and again on April 12, 2017, at 9:54 a.m., masks were observed outside of the resident's room but there was no stop sign to alert staff and visitors to see the nurse for instructions before entering the resident's room. On April 11, 2017, at 1:00 p.m., a family member of the resident was observed questioning the nurse as to why a mask must be worn. In an interviw on April 12, 2017, at 11:00 a.m., the Director of Nursing stated that a sign was to have been placed on the resident's door to alert staff and visitors of the needed for for the use of the mask. 29 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician ordered medications were available for one of 24 sampled residents. (Resident R31) Findings include: Clinical record review revealed that Resident R31 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On the day of admission the physician ordered that staff administer diazepam (a sedative) daily at bedtime for muscle spasms. Review of the February 2017, Medication Administration Record [REDACTED]. In an interview on April 12, 2017, at 2:40 p.m. RN1 confirmed that the medication was not administered for two days. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, review of incident tracking and staff interview, it was determined that the facility failed to provide supervision as per physician's orders [REDACTED]. (Resident R45) Findings include: Clinical record review revealed that Resident R45 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE], revealed the resident was cognitively impaired and required staff assistance with activities of daily living. On December 9, 2016, the physician ordered that staff not leave the resident unattended in the bathroom due to high risk of falls. On March 8, 2017, the physician again ordered that staff not leave the resident alone in the bathroom. On April 5, 2017, a nurse noted that the resident was a high risk for falls and that he was not to be left alone in the bathroom because of his poor safety awareness. Clinical record review revealed that Resident R45 was found on the floor of the bathroom on April 9, 2017 at 7:15 p.m Review of facility incident tracking revealed that the resident was in the bathroom without staff supervision at the time of the fall. The resident sustained [REDACTED]. In an interview on April 13, 2017, at 10:00 a.m., RN 1 confirmed the resident was in the bathroom with no staff supervision at the time of the fall. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, resident and staff interview, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the resident's status for eight of 23 sampled residents. (Residents R16, R41, R47, R61, R68, R81, R88, R92) . Findings include: Clinical record review revealed that Resident R16 had MDS assessments dated December 22, 2014, and March 16, 2015. Both assessments inaccurately identified that the resident required limited to extensive assistance of two staff for bed mobility and transfer. Documentation in the care plan indicated that the resident was independent in transfer. In an interview on April 16, 2015 the resident stated that she was able to reposition herself in bed since admission in December 2014. Clinical record review revealed that Resident R41 had an admission MDS assessment dated [DATE]. The assessment failed to identify that a resident interview was attempted. The resident was alert and oriented and able to make self understood and understands others according to other MDS documentation and nursing documentation. Clinical record review revealed that Resident R47 had an admission MDS assessment dated [DATE]. The assessment failed to identify that a resident interview was attempted. The resident was alert and oriented according to nursing and case manager's documentation. Clinical record review revealed that Resident R61 was admitted to the facility August 3, 2008, with [DIAGNOSES REDACTED]. The next MDS assessment on February 1, 2015, indicated that the resident remained always incontinent of urine, however; the same assessment inaccurately indicated that the resident was on a trailed toileting program. Review of the corresponding care plan indicated that the resident received incontinent care and was not on a trailed toileting program. Clinical record review revealed that Resident R68 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Clinical record review revealed that Resident R81 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's MDS assessments for September 18, 2014 and March 3, 2015, inaccurately indicated that the resident had not been trialed for a toileting program, however, the resident was on a care planned toileting schedule at the time of the assessment. Clinical record review revealed that resident R88 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS assessments for November 4, 2014 and January 28, 2015, inaccurately indicated that the resident's bladder continence had not been trialed for a toileting program, however, the resident was on a care planned toileting schedule at the time of the assessment. Clinical record review revealed that resident R92 was readmitted to the facility September 18, 2014, with [DIAGNOSES REDACTED]. The MDS assessment for readmitted d September 26, 2014, indicated that the resident's bladder continence had not been trialed for a toileting pattern and no current toileting program had been implemented. On March 17, 2015, the MDS assessment inaccurately indicated that the resident's bladder continence had not been trialed for a toileting program, however, the resident was on a care planned toileting schedule at the time of the assessment. In an interview on April 17, 2014 at 10:00 a.m., the Administrator and Resident Assessment Coordinator confirmed that the facility had not accurately assessed and implemented resident's identified needs. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation, it was determined that the facility failed to ensure that potential hazardous products were not accessible to cognitively impaired residents on one of two nursing units. (Second floor) Additionally, based on clinical record review and observation, it was determined that the facility failed to ensure that an assessed safety measure was implemented for one of two residents with falls. (Resident R2) Findings include: Observations during the initial and subsequent tours of the second floor nursing unit conducted on April 14, 2015, April 15, 2015 and April 16, 2015, at various times, revealed four unsecured linen carts with caustic products (hand sanitizer and anti-fungal creams and powders) on the carts. There were 33 cognitively impaired, independently mobile residents that had assess to these potentially harmful products. Clinical record review revealed that Resident R2 had [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. The care plan, most recently reviewed on March 25, 2015, revealed that the resident was to be in a low bed. Observations on April 17, 2015, from 8:40 a.m., through 9:05 a.m., revealed the resident in bed. The bed was not in the low position and there was no staff in the resident's room during the observation. 28 Pa. Code 201.18(b)(1) Management. Previously cited 3/21/14 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, staff interview and observation, it was determined that the facility failed to ensure that individual resident bedrail assessments were documented and accessible for 14 of 20 sampled residents and that a discharge instruction record was completed timely for one of three sampled discharged residents. (Residents R2, R3, R16, R17, R20, R26, R32, R39, R50, R61, R68, R81, R88, R92, CR2) Findings include: Throughout the four days of the survey, Residents R2, R3, R16, R17, R20, R26, R32, R39, R50, R61, R68, R81, R88, and R92 were observed in bed with both upper bedrails in the up position. Clinical record review for all of the aforementioned residents revealed that there was a lack of documented evidence to support that each resident's bedrail use was assessed. In an interview, on April 16, 2015, the Administrator stated that the facility had no documented assessment of these resident's bedrail use. Clinical record review revealed that Resident CR2 was discharged from the facility on February 10, 2015. There was no documentation of discharge instructions in the resident's closed record. 28 Pa. Code 211.5(f) Clinical records. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the responsible party was invited to participate in the resident's interdisciplinary care plan meeting for six of 23 sampled residents. (Residents R3, R17, R32, R39, R61, R68) Finding include: Clinical record review revealed that Resident R3 had a quarterly Minimum Data Set (MDS) assessment dated [DATE], which indicated that the resident was cognitively impaired. There was a lack of evidence to support that the resident's responsible party was invited to participate in the corresponding care plan meeting. Clinical record review revealed that Resident R17 had a quarterly MDS assessment dated [DATE], which indicated that the resident was cognitively impaired. There was a lack of evidence to support that the resident's responsible party was invited to participate in the corresponding care plan meeting. Clinical record review revealed that Resident R32 had a quarterly MDS assessment dated [DATE], and an annual MDS assessment dated [DATE]. There was a lack of evidence to support that the resident's responsible party was invited to participate in the corresponding care plan meeting. Clinical record review revealed that Resident R39 had a quarterly MDS assessment dated [DATE], and an annual MDS assessment dated [DATE] . There was a lack of evidence to support that the resident's responsible party was invited to participate in the corresponding care plan meeting. Clinical record review revealed that Resident R61 had a quarterly MDS assessment dated [DATE], and an annual MDS assessment dated [DATE]. There was a lack of evidence to support that the resident's responsible party was invited to participate in the corresponding care plan meeting. Clinical record review revealed that Resident R68 had an admission MDS assessment dated [DATE], and a significant change in status MDS assessment dated [DATE]. There was a lack of evidence to support that the resident's responsible party was invited to participate in the corresponding care plan meeting.

Based on observation and staff interview, it was determined that the facility failed to ensure safe water temperatures in the facility on two of two nursing units. Findings include: During environmental tours of the nursing units on March 18, 2014, between 08:00 a.m. and 11:00 a.m., water temperatures in various resident's bathrooms and the bathing area on second floor yielded high water temperatures. These water temperatures ranged from 113.7 degrees Fahrenheit to 117.0 degrees Fahrenheit. On March 18, 2014 between 1:30 p.m. and 2:15 p.m., water temperatures up to 116.1 degrees Fahrenheit. In an interview on March 3, 2014, at 11:25 a.m., the Director of Engineering stated that there were low water temperatures on March 14, 2014, and that the facility made adjustments to the water temperatures at that time. The was no documentation after these adjustments were made that the facility conducted any additional water temperature monitoring to ensure that the temperatures did not become too hot. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 205.63(c) Plumbing and piping systems required for existing and new construction.