Every finding on record at Foxdale Village

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services based on current standards of practice for the use of indwelling catheters for two of three residents reviewed for catheter concerns (Residents 30 and 3). Findings include: The facility policy entitled, Infection Control with Indwelling Foley Catheters, last reviewed without changes on March 26, 2024, revealed that if an indwelling Foley catheter (flexible tubing inserted through the urethra into the bladder to drain urine) must be utilized, the facility would implement appropriate interventions to reduce the risk of Catheter Associated Urinary Tract Infections (CAUTI). The cross references listed in the policy included, CDC: Infection Control; CAUTI. The facility policy procedures included that an overnight drainage bag may be changed to a leg bag during waking hours; that the drainage bag should be changed if there is clouding, odor, or discoloration of the drainage bag; and recommended that the indwelling urinary catheter be changed for obstructions that cannot be cleared by irrigation. Review of the orientation checklist performed for newly hired nurse aides revealed that topics included Foley care: changing from a leg bag to a night bag. The current CDC Guideline for Prevention of Catheter-Associated Urinary Tract Infections (https://www.cdc.gov/infectioncontrol/guidelines/cauti/) notes that Proper Techniques for Urinary Catheter Maintenance include: If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Unless obstruction is anticipated (e.g., as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended. If obstruction occurs and it is likely that the catheter material is contributing to obstruction, change the catheter. The facility practice to manage indwelling catheter obstructions by intermittent catheter irrigation and to change collection bags periodically did not adhere to the recommendations referenced in the resource cited as a basis for the facility policy. Clinical record review for Resident 30 revealed active physician orders (dated January 29, 2024), for staff to utilize a 16 French Foley catheter every shift to treat Resident 30's urinary retention. Another active physician's order (dated January 18, 2024) instructed staff to irrigate Resident 30's Foley catheter with 30-60 milliliters (ml) of normal saline every eight hours as needed for obstruction/retention. There were no active physician orders for staff to perform routine Foley catheter changes. Nursing documentation dated July 9, 2024, at 7:19 AM revealed that Resident 30 had her Foley catheter halfway pulled out and was bleeding. Staff removed the catheter and inserted a new catheter. Staff documented that urine was draining out of both the catheter tube and around it. When staff rolled Resident 30 to change the incontinence brief, more than 100 ml of bright red urine drained from the catheter tube. Review of Resident 30's Treatment Administration Record (TAR, electronic documentation of the completion of treatments by the licensed nurse) dated July 2024, revealed that staff irrigated Resident 30's catheter on July 10, 2024, at 10:11 PM and July 14, 2024, at 09:17 AM. Nursing documentation dated July 11, 2024, at 4:30 AM revealed that when Resident 30 went to bed the previous evening, staff noted that she did not have any urine output in her catheter bag. Once in bed, and rolled over for care, staff noted a large amount of hematuria (bloody urine) leaking around the catheter onto the pad and bed. The documentation indicated that staff irrigated the catheter, later. That morning, Resident 30 had 300 ml of dark red hematuria noted in the catheter bag. Review of nurse aide electronic documentation dated October 2024, revealed that nurse aide staff documented a change of Resident 30's catheter bag weekly on Thursdays (therefore breaking the closed system). There was no evidence that the facility staff changed Resident 30's indwelling urinary catheter since July 9, 2024, (more than three months earlier than the onsite survey) or routinely changed Resident 30's indwelling Foley catheter; however, staff broke the closed system repeatedly for collection bag changes and as needed for irrigation. The surveyor reviewed the above concerns regarding the facility's policy, practice, and CDC recommendations as well as Resident 30's Foley catheter maintenance during interviews with the Director of Nursing and Employee 1 (assistant nursing home administrator) on October 30, 2024, at 2:15 PM, and October 31, 2024, at 2:15 PM. Observation of Resident 3 on October 29, 2024, at 1:30 PM revealed that he had an indwelling foley catheter and a urine collection bag was attached to his bed. Clinical record review for Resident 3 revealed current physician orders for staff to provide catheter care every shift, irrigate the catheter with 60 ml of normal saline solution for poor flow as needed, and change the foley catheter as needed if unable to irrigate. Further clinical record review of Resident 3's TAR revealed that his catheter was irrigated on August 28, 2024, September 19, 2024, September 23, 2024, and on October 1, 2024, due to poor flow. His catheter was not changed until October 1, 2024, after staff were unable to irrigate it, even though the closed system was compromised on August 28, 2024, September 19, 2024, and September 23, 2024. The Director of Nursing and Employee 1 were made aware of the concerns with Resident 3's catheter during a meeting on October 30, 2024, at 2:30 PM. The facility failed to provide treatment and services based on current standards of practice for the use of indwelling catheters for Resident 3. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure the application of physician ordered supplemental oxygen consistent with professional standards of practice for three of three residents reviewed for supplemental oxygen concerns (Residents 9, 16, and 30). Findings include: Clinical record review for Resident 9 revealed an active physician order dated October 1, 2024, for staff to apply supplemental oxygen at two liters per minute (lpm) as needed for hypoxia (too little oxygen delivered to body tissues), SPO2 (pulse oximeter, or pulse ox, works by shining a light through the skin and determining the amount of oxygen based on how the light travels through the skin and blood vessels) of less than 90 percent. Observation of Resident 9 on October 30, 2024, at 11:24 AM revealed no supplemental oxygen in use. Review of Resident 9's medication administration record (MAR, electronic documentation by licensed nursing staff of the completion of medications) and treatment administration record (TAR, electronic documentation by licensed nursing staff of the completion of treatments) dated October 2024, revealed that no staff documented an assessment of Resident 9's SPO2 or the application of supplemental oxygen. Review of documentation in Resident 9's electronic medical record (EMR) weights and vital sign assessments revealed the following SPO2 entries: October 30, 2024, at 3:25 AM, 94.0 percent October 29, 2024, at 2:54 PM, 95 percent October 29, 2024, at 2:52 PM, 95 percent October 4, 2024, at 2:38 AM, 94 percent October 2, 2024, at 8:00 PM, 93 percent The available documentation indicated that Resident 9 went most days without an assessment of her SPO2 percentage although her physician's order for supplemental oxygen was contingent on this assessment. Review of plans of care developed by the facility to meet Resident 9's care needs revealed no plan of care or intervention that addressed her potential use of supplemental oxygen. Further review of Resident 9's EMR revealed that staff discontinued the physician order for supplemental oxygen on October 30, 2024, at 6:35 PM (after the surveyor's questioning). Clinical record review for Resident 16 revealed an active physician's order dated December 31, 2022, for staff to apply supplemental oxygen at two lpm as needed for an SPO2 less than 89 percent. Observation of Resident 16 on October 30, 2024, at 10:39 AM revealed no supplemental oxygen in use. Review of Resident 16's MAR and TAR dated August, September, and October 2024, revealed that no staff documented an assessment of Resident 16's SPO2 or the application of supplemental oxygen. Review of documentation in Resident 16's EMR weights and vital signs assessments revealed the following SPO2 entries: No entries for October 2024 September 30, 2024, at 11:02 PM, 92 percent September 29, 2024, at 4:59 AM and 5:04 AM, 92 percent September 11, 2024, at 4:15 AM, 93 percent August 21, 2024, at 3:00 PM, 91 percent August 18, 2024, at 4:31 AM and 11:36 PM, 95 and 91 percent respectively August 16, 2024, at 11:37 AM and 6:36 PM, 96 and 92 percent respectively August 10, 2024, at 11:16 AM, 92 percent August 7, 2024, at 4:47 PM, 99 percent August 5, 2024, at 3:28 PM, 92 percent The available documentation indicated that Resident 16 went most days without an assessment of her SPO2 percentage although her physician's order for supplemental oxygen was contingent on this assessment. The surveyor reviewed the concern that Resident 9 and 16's supplemental oxygen order was contingent on an SPO2 assessment; however, there was no evidence that staff obtained SPO2 assessments routinely, during an interview with Employee 1 (assistant nursing home administrator) and the Director of Nursing on October 30, 2024, at 2:15 PM. Further review of Resident 16's EMR revealed that staff discontinued the physician order for supplemental oxygen on October 30, 2024, at 4:03 PM (following the surveyor's questioning). Clinical record review for Resident 30 revealed an active physician's order dated December 16, 2023, for staff to administer supplemental oxygen at two lpm as needed for an SPO2 less than 90 percent or shortness of breath/wheezing as needed. Observation of Resident 30 on October 30, 2024, at 10:53 AM revealed no supplemental oxygen in use. Review of Resident 30's MAR and TAR dated August, September, and October 2024, revealed the application of supplemental oxygen with SPO2 assessments on nine occasions in August 2024, five occasions in September 2024, and seven occasions in October 2024. Review of documentation in Resident 30's EMR weights and vital signs assessments revealed inconsistent documentation (not daily or every shift) of SPO2 assessments were obtained. Staff failed to document an SPO2 assessment on 14 of 31 days in August 2024, on 8 of 30 days in September 2024, and on 15 of 31 days in October 2024. Review of plans of care developed by the facility to meet Resident 30's care needs revealed that a plan of care to address supplemental oxygen use was discontinued on August 14, 2021, and there was no evidence of another plan of care that addressed Resident 30's supplemental oxygen use until October 29, 2024 (first day of the onsite survey). The surveyor reviewed the above concerns regarding Resident 30's supplemental oxygen use during an interview with Employee 1 and the Director of Nursing on October 30, 2024, at 2:15 PM. Further review of Resident 30's EMR revealed that staff revised the physician's order for supplemental oxygen on October 30, 2024, at 4:00 PM (following the surveyor's questioning), to now prompt staff to obtain an SPO2 assessment every shift. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, observations, and staff and resident interview, it was determined that the facility failed to ensure the availability of necessary emergency supplies for one of one resident reviewed receiving hemodialysis (Residents 23). Findings include: Clinical record review for Resident 23 revealed he had a tunneled catheter (a thin flexible tube that is inserted into a large vein in the chest that is used to access blood for dialysis) located in his right chest for dialysis treatment. A current physician's order for Resident 23 dated indicated he was to receive hemodialysis (a machine that performs a basic function of the kidney by cleansing the blood of impurities) every Monday, Wednesday, and Friday at a dialysis center. Observation of Resident 23 in his room on October 31, 2024, at 1:00 PM with Employee 5, Licensed Practical Nurse (LPN), revealed a clear dressing over his dialysis catheter located on his right chest. Concurrent interview of Employee 5, the LPN responsible for Resident 23 at that time, revealed that she was unsure where the emergency supplies were located that may be necessary to control bleeding that could occur if the catheter dislodged or came apart. She looked for supplies in the room and was not able to locate them. A review of Resident 23's plan of care revealed no evidence of emergency care related to his dialysis catheter, until after the surveyor addressed the issue with the Director of Nursing and Employee 1, Assistant Nursing Home Administrator, on October 31, 2024, at 2:20 PM. An interview with the Director of Nursing on November 1, 2024, at 10:32 AM revealed that she corrected the care plan, and that the emergency supplies were in Resident 23's room taped to the side of his nightstand. The facility failed to ensure that emergency supplies were available and emergency care was addressed in Resident 23's plan of care related to his dialysis catheter. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care related to physician ordered devices for one of 13 residents reviewed (Resident 30). Findings include: Clinical record review for Resident 30 revealed an active physician's order dated June 30, 2022, for staff to apply compression stockings in the morning and remove them at hour of sleep every day and evening shift for deep vein thrombosis prophylaxis (the prevention of blood clots in the veins of the leg). An active physician order dated October 14, 2024, instructed staff to apply a palmar roll up splint (soft splint worn on the hand, on the inside of contracted fingers, to prevent damage from fingernails) to Resident 30's left hand, applied in the morning, and removed in the evening. A plan of care developed by the facility to address Resident 30's restorative nursing program for a passive range of motion program to prevent tightness of muscles and promote flexibility to prevent contractures (initiated June 14, 2024) revealed no intervention pertaining to the left-hand splint. A plan of care developed by the facility to address Resident 30's deficits to perform activities of daily living included interventions that listed a left-hand palm guard as tolerated that was assigned to the nurse and the nurse aide. Observation of Resident 30 on October 30, 2024, at 10:50 AM revealed no splint on her left hand. Observation of Resident 30 with Employee 6 (physical therapy assistant) on October 31, 2024, at 3:16 PM revealed that Resident 30 wore black socks, which Employee 6 pulled back freely from the skin of Resident 30's lower extremities. The elastic of the black socks allowed a wide opening to view the skin of Resident 30's shins. The observation also confirmed that Resident 30 did not have a splint on her left hand. Interview with Employee 7 (nurse aide who confirmed his assignment to Resident 30's care) on October 31, 2024, at 3:20 PM indicated that he believed the socks on Resident 30 were compression stockings (although they freely expanded away from her skin to expose her shin and did not compress her legs). Employee 7 expressed no knowledge of Resident 30's left hand splint. Interview with Employee 8 (nurse aide who confirmed her assignment to Resident 30's care) on October 31, 2024, at 3:22 PM indicated that she had no knowledge of Resident 30's left hand splint. Interview with Employee 9 (occupational therapist) on October 31, 2024, at 3:23 PM revealed that she was familiar with the splint ordered for Resident 30. Employee 9 went to Resident 30's room, obtained the splint, and applied the splint to Resident 30's left hand while she was in the nursing unit's common activity area. The surveyor reviewed the above concerns regarding Resident 30's splint and compression stockings during an interview with the Director of Nursing and Employee 1 (assistant nursing home administrator) on October 31, 2024, at 3:30 PM. The surveyor confirmed during the interview that nurse aide staff documented the application of compression stockings twice daily during the week of the onsite survey although the observation revealed socks that did not compress Resident 30's lower extremities. The interview indicated that when therapy staff submit a physician's order for a splinting device it is supposed to generate a restorative nursing program, which will prompt the need for documentation by the nurse aides completing the tasks; however, the order entered for Resident 30's left hand splint did not include the necessary prompts for any staff to document the application of, or refusal of, the device (either on the nurse aide task list or the medication administration record/treatment administration record). 28 Pa. Code 211.5(f)(i)-(xi) Medical records 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 provide written notice regarding the facility's bed-hold policy for one of one resident reviewed for hospitalization concerns (Resident 16). Findings include: Clinical record review for Resident 16 revealed nursing documentation dated August 3, 2024, at 5:00 PM that Resident 16 had a fall, hit the back of her head, sustained a head laceration, and was sent to the hospital emergency room for evaluation. Nursing documentation dated August 3, 2024, at 9:04 PM revealed that the hospital admitted Resident 16 for observation and hypoxia (low oxygen levels). Nursing documentation dated August 5, 2024, at 1:09 PM revealed that staff left a voicemail message with Resident 16's daughter regarding holding the bed due to Resident 16's hospital admission and staff were waiting for a return call. There was no evidence that facility staff mailed or provided written notice of the facility's bed-hold policy to Resident 16's responsible party within 24 hours. Nursing documentation dated August 5, 2024, at 3:55 PM revealed that Resident 16 returned to the facility, accompanied by her daughter. The documentation did not indicate that staff attempted to provide the written notice of the facility's bed-hold policy at that time. The surveyor requested evidence that the facility provided Resident 16's responsible party the written bed-hold policy notice during an interview with Employee 1 (assistant nursing home administrator) and the Director of Nursing on October 30, 2024, at 2:15 PM. The surveyor requested evidence that the facility provided Resident 16's responsible party the written bed-hold policy notice during an interview with the Director of Nursing on October 31, 2024, at 9:53 AM. Interview with Employee 1 and the Director of Nursing on November 1, 2024, at 9:15 AM confirmed that the facility could not provide evidence of written notification to Resident 16's responsible party of the facility's bed-hold policy within 24 hours of her hospitalization on [DATE]. The facility failed to provide Resident 16's responsible party written information related to holding beds during absences from the facility, regardless of her payment source, within 24 hours of her emergency transfer. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection for one of one resident reviewed for COVID-19 transmission-based precaution (TBP) concerns (Residents 18). Findings include: Clinical record review for Resident 18 revealed she had a positive COVID-19 result dated October 26, 2024. Observation of Resident 18's room revealed she had a temporary door with magnetic closures covering her doorway. There was a sign on the door that indicated she was on droplet precautions (precautions taken to prevent the spread of infection that is transmitted by coughing, sneezing, or talking). The sign indicated that those entering the room should wear personal protective equipment (PPE) to include a gown, gloves, and an N-95 mask (a face mask that is used to protect against airborne particles) to enter the room. Observation of Resident 18 at 12:13 PM on October 29, 2024, revealed Employee 4 (nurse aide) preparing to enter Resident 18's room. She applied an N-95 mask, a gown, and gloves. She entered the room and then a dietary staff member handed her Resident 18's meal tray into the room. After Employee 4 was finished in Resident 18's room, she exited through the magnetic door opening, with her mask, gown, and gloves still on. She removed them all in the hallway and placed then in a red bin that was located right outside the door. Concurrent interview with Employee 4 revealed that the facility's expectation is for her to exit the room and remove her gown, gloves, and N-95 mask in the hallway and place them in the red bin located just outside Resident 18's room. Review of Employee 4's competency dated June 27, 2024, for donning (putting on) and doffing (removal, taking off) personal protective equipment (PPE) revealed that all PPE should be removed prior to exiting the room. Interview with the Director of nursing on October 31, 2024, at 9:40 AM revealed that Employee 4 should have removed her PPE in Resident 18's bathroom and placed it in the red bin located there. The facility failed to ensure an environment free from the potential spread of infection related to TBP for COVID-19. 28 Pa. Code 201.18(b)(3)(d)(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to protect the rights of a resident to be free from neglect by not providing the services necessary to avoid physical harm resulting in fractures for one of two residents reviewed (Resident 1). Findings include: An observation of Resident 1 on January 23, 2024, at 11:35 AM revealed she was in an activity with her head down. An alarm box was noted on her wheelchair. Clinical record review for Resident 1 revealed that the facility admitted her on September 8, 2023. A progress note date December 29, 2023, at 9:15 PM revealed that the nurse aide (NA) notified the registered nurse (RN) that Resident 1 fell and hit the back of her head. Resident 1was observed by the RN sitting in the hallway on the carpeted floor near the parlor. Resident 1 was bleeding from the back of her head and was noted to have a laceration on the right side of the back of her head. The RN notified the certified registered nurse practitioner and received orders to send Resident 1 to the emergency room . Further clinical record review revealed that Resident 1 returned from the emergency roiagnom on [DATE], at 11:03 AM. She was wearing a cervical soft collar. Review of the emergency room report revealed that she had a displaced fracture (bone breaks in two or more places and moves out of alignment) of the left sixth cervical vertebrae (near the base of the neck) and a transverse process remote deformity (a break or crack in one of the wing-like sides at the back of a vertebrae) of the thoracic vertebrae T3 (middle section of your spine, third segment of the 12 thoracic vertebrae). She also had 9 sutures intact to the right posterior (back) scalp laceration. Review of the facility's investigation into Resident 1's fall revealed that Employee 1 forgot to move the alarm box from the resident's chair to her bed on December 29, 2023, at approximately 8:30 PM. A witness statement from Employee 1, NA, indicating that she neglected to move the alarm box from Resident 1's chair onto her bed. Review of Resident 1's care plan entitled Potential for Falls initiated on September 8, 2023, revealed an intervention for Resident 1 to have a silent bed and chair alarm for resident safety. Further clinical record review for Resident 1 revealed a care plan for activities of daily living self-care performance deficit with an intervention that was initiated on September 22, 2023, indicating Resident 1 required the assistance of one to ambulate and transfer in her room and in the hallway Review of Resident 1's fall risk evaluation dated December 12, 2023, indicated her score was 16. The form noted that a score of 10 or higher indicated the resident was a high risk for falls. Review of the nurse aide point of care (POC) documentation (a computerized system where resident care needs are identified and documented) for Resident 1 revealed that Employee 1 had access to the care plan. The care plan indicated that Resident 1 was to have silent bed and chair alarms. Review of the POC task for Resident 1 revealed that she was to have mobility monitors bed and chair alarms for resident safety initiated September 13, 2023. The facility's investigation revealed that Employee 1 was educated on December 29, 2023, at 9:15 PM on following the resident's care plan. She was also educated on January 3, 2024, on abuse and the facility's policy and procedure on abuse. Review of Employee 1's personnel file revealed that she received annual education for falls on November 6, 2023, that included fall prevention. She also received annual education on care plans in December 2023, and that a resident's care plan provides direction to staff on what care and services a resident required. Interview with the Nursing Home Administrator on January 23, 2024, at 9:50 AM revealed that the facility only educated Employee 1 and that they did not educate other staff that would be responsible for fall prevention and following care plans, to prevent this from reoccurring. The above findings were reviewed during an interview with the Nursing Home Administrator and Director of Nursing on January 23, 2024, at 12:00 PM. The facility failed to prevent neglect that resulted in harm for Resident 1. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations for four of five residents reviewed (Residents 3, 10, 21, and 30). Findings include: Review of the policy entitled Pharmacy Monthly Drug Regimen Review, last reviewed on March 22, 2022, indicates that the Director of Nursing or designee will assure that recommendations associated with drug irregularities are communicated to the attending physician within three days from the receipt of the report. Review of Resident 3's clinical record revealed that the facility's pharmacist made recommendations to his physician on April 28, 2022, for the consideration of a gradual dose reduction for the use of his Risperdal (an antipsychotic used to treat certain mood or mental disorders). The pharmacy recommendation was not addressed by Resident 3's physician until December 1, 2022, after questioning from this surveyor. Review of Resident 10's clinical record revealed that the facility's pharmacist made recommendations to her physician on March 23, 2022, for the consideration of a gradual dose reduction for the use of her Seroquel (an antipsychotic used to treat certain mood or mental disorders). There was no documented evidence in Resident 10's clinical record to indicate that her physician addressed the pharmacist's recommendation. Interview with the Administrator on December 1, 2022, at 1:23 PM confirmed the above findings for Resident 10. Review of Resident 21's clinical record revealed that the facility's pharmacist made recommendations to her physician on July 21, 2022, for the consideration of a gradual dose reduction for the use of her Lexapro (a medication used to treat depression or anxiety). There was no documented evidence in Resident 21's clinical record to indicate that her physician addressed the pharmacist's recommendation. Review of Resident 30's clinical record revealed that the facility's pharmacist made recommendations to her physician on March 24, 2022, for the consideration of a gradual dose reduction for the use of her Buspar (a medication used to treat anxiety). The pharmacy recommendation was not addressed by Resident 30's physician until December 1, 2022, after questioning from the surveyor. Interview with the Administrator and Director of Nursing on December 1, 2022, at 2:00 PM, acknowledged the above findings for Residents 3, 10, 21, and 30. 28 Pa. Code 211.2(a)(k) Physician services 28 Pa. Code 211.12(d)(3) Nursing services

Based on observation, clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to assess for the risk of grab/enabler bar entrapment, review the risk and benefits of grab/enabler bar utilization with the resident or resident representative, and receive consent for the use of grab/enabler bars for four of four residents reviewed (Residents 2, 10, 15, and 20). Findings include: The facility policy entitled Bed Rail Use, last reviewed without changes on March 26, 2020, indicated that the facility will identify and reduce safety risks and hazards commonly associated with bed rail use. Facility leadership will be responsible for completing individual bed rail evaluations on a regular basis, providing education to staff and the resident or resident's representative pertaining to resident specific risks, benefits, and care needs associated with bed rail use, and obtaining an informed consent. Observation of Resident 2's room on December 15, 2020, at 10:32 AM revealed that there was a grab/enabler bar (a bar to assist with positioning/mobility/transfer in bed) on the left (closet) side of her bed. Clinical record review for Resident 2 revealed a care plan that indicated her grab/enabler bar was to assist with bed mobility. There was no evaluation to identify and ensure that there were no entrapment zones for Resident 2's left sided grab/enabler bar. Observation of Resident 10's room on December 15, 2020, at 10:41 AM revealed that there was a grab/enabler bar on the left (window) side of his bed. Clinical record review for Resident 10 revealed a care plan that indicated his grab/enabler bar was to assist with bed mobility. There was no evaluation to identify and ensure that there were no entrapment zones for Resident 10's left sided grab/enabler bar. Observation of Resident 20's room on December 16, 2020, at 9:23 AM revealed that the left side of her low bed was padded and placed against the wall. There was a grab/enabler bar (a bar to assist with positioning/ mobility/ transfer in bed) on the right (room) side of her bed. Clinical record review for Resident 20 revealed a care plan that indicated her grab/enabler bar was for safety. There was no informed consent for the use of grab bars, nor was there documentation that the facility reviewed the potential risks and benefits of the use of grab bars with either the resident or the resident's responsible party. The surveyor reviewed the above information for Residents 2, 10, and 20 during an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on December 18, 2020, at 9:05 AM. The NHA confirmed the above findings. An observation of Resident 15 on December 15, 2020, at 11:20 AM revealed the resident in bed with an enabler bar raised on the bed to the resident's left side. Clinical record review for Resident 15 revealed the resident was assessed on June 11, 2020, as needing the left enabler bar as a medical necessity. Further review did not reveal any evidence that the potential risk and benefits of the enabler bar were reviewed with the resident's responsible party or that informed consent was obtained for the enabler bar. In an interview with the NHA on December 18, 2020, at 11:48 AM, the NHA confirmed the above findings regarding Resident 15. 28 Pa. Code 211.12 (d)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure the highest practicable pain management for one of one resident reviewed (Resident 12). Findings include: The policy entitled, Pain Management Program, last reviewed without changes on March 20, 2020, revealed that orders for [MEDICATION NAME] medications are received from the resident's physician. The order will include the pain scale for the medication. Staff should administer [MEDICATION NAME] based on the physician's orders [REDACTED]. Clinical record review for Resident 12 revealed a physician's orders [REDACTED]. The physician order [REDACTED]. A physician's orders [REDACTED]. The physician order [REDACTED]. A physician's orders [REDACTED]. The physician order [REDACTED]. Review of Resident 12's Medication Administration Record [REDACTED]. There was no documented evidence to indicate that nursing staff administered the [MEDICATION NAME] to Resident 12 prior to the [MEDICATION NAME] as per the physician order. Review of Resident 12's MAR indicated [REDACTED]. There was no documented evidence to indicate that nursing staff administered the [MEDICATION NAME] to Resident 12 prior to the [MEDICATION NAME] as per the physician order. Review of Resident 12's MAR indicated [REDACTED]. There was no documented evidence to indicate that nursing staff administered the [MEDICATION NAME] to Resident 12 prior to the [MEDICATION NAME] as per the physician order. Review of Resident 12's MAR indicated [REDACTED]. There was no documented evidence to indicate that nursing staff administered the [MEDICATION NAME] to Resident 12 prior to the [MEDICATION NAME] as per the physician order. Interview with the Administrator on December 17, 2020, at 3:10 PM, confirmed the above findings. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies, observation, and staff interview, it was determined that the facility failed to store and prepare food items in a safe and sanitary manner in the facility's main kitchen and on one of three nursing units (East). Findings include: Review of the facility policy entitled Sanitation and Infection Control Cleaning Schedules, last reviewed on (MONTH) 26, 2019, revealed cleaning schedules are used to maintain high levels of sanitation in the Food and Nutritional services department and cleaning tasks are assigned to various staff members. It also indicates heavy cleaning such as under equipment, walls, floors, and major equipment can be planned on a weekly basis. Review of the facility policy entitled Meal Service Remote(NAME)Washing, last reviewed on (MONTH) 26, 2019, indicates the facility will follow established methods for the safe and effective use of the dish machine in the remote dining areas, and that a temperature log will be maintained for each machine for recording of wash and final rinse temperatures. The policy also revealed the dietary aide will record the temperature for breakfast, lunch, and dinner. Initial tour of the facility's main kitchen on (MONTH) 21, 2019, at 9:25 AM revealed the dry storage room was filled with open wire shelving units. Dry food products were stored on the bottom shelf of the units throughout. There was no barrier to protect the food products from being contaminated from splash from mop water or debris from sweeping. Several of the metal racks contained a buildup of dust and debris on the bases and shelf edges. A dolly (a square solid base with wheels) containing a stack of boxes of chips and snacks contained dust and debris. The large walk-in freezer floor contained frozen spills and dried food and debris throughout and a significant amount under the shelving. The freezer also contained open wire metal shelving units. Food products were stored on the bottom shelf with no protection from contamination of mop water splash or dirt and debris from sweeping. The ramp entering the freezer also had a significant amount of dirt/debris. A speed rack (wheeled shelving unit that holds sheet tray pans) was in walk-in cooler number one. The rack was holding sheet trays that contained pans of stewed tomatoes and pastry dough. The trays holding the items had a significant amount of dried food debris on them. Walk-in cooler number one also contained a clear plastic container labeled tartar sauce, on a cooler shelf. The lid to the container was covered in a yellow powdery substance. A bulk container of thousand island dressing had ,[DATE] written on the lid. A bulk container of french dressing was also on the shelf with a date of ,[DATE] written on the lid. There was no indication as to whether the date on these products was the date opened, date received, or date expired. In a concurrent interview with Employee 1, director of dining services, he stated he believed the date was when the facility received the bulk dressing and was not able to identify when the product was opened, or when it expired. The floor in the walk-in cooler was also covered in dirt and debris. The floor of walk-in cooler number three contained dirt/debris throughout the floor and under shelving. The double stacked convection oven had drips of a dark brown sticky substance in multiple areas outside the oven doors. The interior of both ovens contained metal sheet tray pans on the bottom of both ovens with pieces of foil sticking up, the trays and foil were coated in dried brown debris. There were large pieces of dried brown debris piled in the corners of the ovens and at door edges. The interior of the oven doors was coated in a thick brown substance. The shelf of the steam table contained dust and debris. A garnish refrigerator beside the steam table held oranges, lemons, and other garnish items. The items did not have any date on them to indicate when they were put in use or when to use them by. The lower part of the refrigerator had a bag of bread with no label or expiration date, and a container of what Employee 1 identified as butter with no label or date. Two dollies holding racks of glassware were dirty and dusty. Two open wire shelving units were holding serving pans and dishes on the bottom shelf of the unit. The pans were filled with the serving side facing the floor. The bottom shelf did not contain and barrier to prevent the potential from contamination splash from mopping or sweeping the floor. The above findings were concurrently reviewed with Employee 1. A tour of the East kitchenette on (MONTH) 21, 2019, at 10:11 AM revealed the unit contained a small household size dishwasher. In an interview with Employee 2, dietitian, she indicated that all the dishware from serving residents in that area gets washed in that dishwasher on the unit. A concurrent review of the temperature log for the dishwasher revealed temperatures were recorded for (MONTH) 21, 2019, for breakfast with a wash temperature of 170 degrees Fahrenheit, and a final rinse temperature of 180 degrees Fahrenheit with the initials LS, beside them. Further review of the temperature log also revealed temperatures were recorded for (MONTH) 21, 2019, lunch meal, with a wash temperature of 171 degrees Fahrenheit and a final rinse temperature of 183 degrees with the initials LS, beside them. The time of the observation was 10:11 AM, and Employee 2 confirmed lunch had not been served yet. In an interview with Employee 3, dietary aide, she stated she did record the temperatures for (MONTH) 21, 2019, and they were her initials on the temperature log. She stated she did not know why she recorded temperatures for lunch when the meal had not even been served. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on (MONTH) 22, 2019, at 2:00 PM. 28 Pa. Code 211.6 (c)(d) Dietary services

Based on review of select facility policies, observation, and staff interview, it was determined that the facility failed to provide an environment free from the potential spread of infection regarding bedpans for one of three nursing units (North Nursing Unit) and Oxygen equipment for two of two residents reviewed (Resident 1 and 10). Findings include: Review of the facility policy entitled Cleaning and Disinfection of Resident-Care Items and Equipment, last reviewed without changes on (MONTH) 26, 2019, revealed that resident care equipment, including reusable items and durable medical equipment, will be cleaned and disinfected according to current Centers for Disease Control and Prevention and the Occupational Safety and Health Administration Bloodborne Pathogens Standard. Observation of the North Nursing Unit on (MONTH) 21, 2019, at 9:48 AM revealed that staff had placed an uncovered urine hat (a container to measure urine) or an uncovered bedpan between the shower handrail and the shower tile on the wall in the following Resident Rooms: Resident room [ROOM NUMBER], urine hat Resident room [ROOM NUMBER], bedpan Resident room [ROOM NUMBER], bedpan Resident room [ROOM NUMBER], fracture bedpan Resident room [ROOM NUMBER], bedpan Continued observation of the North Nursing Unit on (MONTH) 22, 2019, at 9:25 AM and on (MONTH) 23, 2019, at 9:38 AM revealed that the following Resident Rooms continued to have an uncovered urine hat or bedpan in between the shower handrail and shower wall tile as noted above: Resident room [ROOM NUMBER], urine hat Resident room [ROOM NUMBER], bedpan Resident room [ROOM NUMBER], fracture bedpan Observation of Resident 1's room on (MONTH) 21, 2019, at 9:55 AM revealed that her Oxygen concentrator was turned off beside her bed. The nasal cannula (a device used to deliver supplemental oxygen) was uncovered, not bagged and draped over the top of the concentrator. Observation of Resident 10's room on (MONTH) 21, 2019, at 11:33 AM revealed that his Oxygen concentrator was by his bed and turned on. Resident 10's nasal cannula was lying on the floor beside the concentrator, uncovered and not bagged. Immediately prior to this observation (11:30 AM), staff were observed leaving Resident 10's room. Interview with the Nursing Home Administrator and the Director of Nursing on (MONTH) 22, 2019, at 2:00 PM acknowledged the above findings. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Previously cited 6/29/18

Based on observation, clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of two residents reviewed (Resident 1). Findings include: Review of the facility policy entitled Oxygen: Administration and Equipment, last reviewed without changes on (MONTH) 26, 2019, revealed that the facility will support residents in need of Oxygen therapy. Staff will verify that there is a physician's order and review the facility's protocol for Oxygen administration. After completing the Oxygen setup and/or adjustment, staff will document Oxygen administration in the resident's medical record. Clinical record review for Resident 1 revealed on (MONTH) 15, 2019, her physician ordered Oxygen 2 liters per minute (LPM) via nasal canula (NC, a device used to deliver supplemental oxygen) for SpO2 (pulse oxygenation, the amount of Oxygen in the bloodstream) less than or equal to 89 percent room air (RA) every shift for decreased SpO2. Review of a facility form entitled, Weights and Vitals Summary, a form used to document a resident's weight, blood pressure, pulse, respirations, temperature, and SpO2, revealed that staff failed to administer Oxygen to Resident 1 with an identified SpO2 less than or equal to 89 percent on room air on the following dates and times: March 2, 2019, at 1:30 AM 85 percent RA April 3, 2019, at 2:47 PM 88 percent RA April 15, 2019, at 3:19 PM 89 percent RA April 17, 2019, at 9:13 AM 89 percent RA April 3, 2019, at 1:44 AM 86 percent RA April 30, 2019, at 3:14 PM 88 percent RA Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 24, 2019, at 10:44 AM confirmed the above findings. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12 (d)(1)(5) Nursing services Previously cited 6/29/18

Based on select facility polices, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure an environment free from potential accident hazards related to elopement for two of two residents reviewed and to prevent accidents related to falls for one of 5 residents reviewed. (Residents 6, 9, and 20) Findings include: The facility policy entitled, Elopement Protocol for Skilled Nursing last reviewed without changes on (MONTH) 26, 2019, defined elopement as the resident exiting the facility without staff knowledge and potential elopement as when a resident leaves their area of the skilled nursing unit to another neighborhood of the Skilled nursing facility without staff knowledge. Residents on the East neighborhood (unit) who have attempted elopement or have other behaviors to suggest possible elopement, will wear a wander alert device until they can be moved to a secured neighborhood. Review of the facility policy entitled Falls Prevention, last reviewed on (MONTH) 26, 2019, revealed the facility's goal was to maintain the resident's environment as free from fall hazards while providing adequate support for the resident. The licensed nurse is responsible to implement appropriate interventions immediately after the fall based on the identified cause and the resident's care plan will be updated at the time the intervention is placed. Observation on (MONTH) 21, 2019 at 10:14 AM revealed Resident 6 ambulating in the hallway with her walker. She stated to the surveyor that she wished there was a way for her to go outside. She went to the end of the hallway where the door opens to the outside and noted that the alarm would go off if she went out that door. Resident 6 then turned and started toward the end of the hallway that would lead to the main lobby of the facility and stated that she will have to go out that way pointing to a door that exits the unit to the facility lobby. Resident 6 has a BIMs (Brief Interview for Mental Status) of 7 on her most recent quarterly MDS (an assessment performed by the facility to determine the resident care needs) dated (MONTH) 15, 2019, indicating that her cognition is severely impaired. Resident 6 started ambulating to the doorway and stated she better go to the bathroom first and went back towards her room. The surveyor noted the lobby entrance doors were unattended at least 3 times when the receptionist was not at her desk on (MONTH) 21, 2019, at 12:30 PM, (MONTH) 21, 2019, at 2:50 PM, and (MONTH) 22, 2019, at 2:55 PM. Clinical record review for Resident 6 revealed that the facility completed a wandering risk assessment on her on (MONTH) 4 and (MONTH) 15, 2019, and determined she was at moderate risk for wandering. Further clinical review revealed a health status noted dated (MONTH) 19, 2019, at 5:57 PM that indicated Resident 6 continued to wander throughout the unit and was adamant about leaving. She was standing in the hallway outside the dining area. The facility initiated 15 minute checks on the resident. A health status note dated (MONTH) 1, 2019, at 8:13 PM revealed that at approximately 4:30 PM, Resident 6 was agitated. She ambulated out of her room and requested to go to the main dining room off the unit for dinner and wanted to go right away. Staff offered to assist Resident 6 at 5:30 PM. At 5:00 PM Resident 6 stated she refused to wait any longer and began to ambulate with her walker to the unit doors. The nurse aide notified the licensed nurse and then accompanied the resident to the dining room. A health status note dated (MONTH) 18, 2019, at 4:02 PM revealed that Resident 6 ambulated alone up to cafe prior to lunch to visit with the pastor and receive communion. Staff reinforced for her to wait for someone to accompany her. Resident 6's most recent BIMS score prior to this event was a 3 from her MDS dated (MONTH) 13, 2019, indicating severe cognitive impairment. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 23, 2019, at 9:45 AM revealed that Resident 6 does not have a wander alert device as per policy and is an elopement risk. Clinical record review for Resident 9 revealed that on (MONTH) 1, (YEAR), she was observed in the hallway near the medical home (not part of the skilled nursing unit) at 9:30 AM. Resident 9's BIMs score on the MDS prior to this event was not able to be completed by questioning the resident on (MONTH) 21, (YEAR). The staff assessment on the MDS dated (MONTH) 21, (YEAR), revealed Resident 9 had a memory problem. Review of the facility investigation into this event revealed that Resident 9 was cognitively impaired. Resident 9 was sitting in the living room on East hall prior to leaving the unit. Resident 9 had no prior attempts at leaving the nursing unit. The facility noted the contributing factors to this event to be a change in mental status with confusion. Upon her return to the unit, Resident 9 was provided a wander bracelet. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 23, 2019, at 9:45 AM confirmed the above noted findings related to Resident 6 and 9. Clinical record review for Resident 20 revealed the resident was admitted to the facility on (MONTH) 26, (YEAR). Further clinical record review revealed a Morse Fall Scale (an assessment to determine fall risk) was completed on (MONTH) 26, (YEAR), (admission), assessing the resident as a high risk for falling. Review of Resident 20's plan of care revealed a falls care plan initiated on (MONTH) 26, (YEAR), (admission), which indicated the resident had a history of [REDACTED]. Review of Resident 20's quarterly MDS (Minimum Data Set, an assessment completed at periodic intervals to assess resident care needs) completed on (MONTH) 2, (YEAR), revealed the resident has a BIMS (Brief interview for Mental Status) score of four, which indicates severe impairment, and was independent with set up only for bed mobility, eating, and transfers. The resident was assessed as needing supervision of setup only for walking in her room and corridor, and supervision of one person physical assist dressing, toilet use, and personal hygiene. Review of facility fall investigations revealed the following for Resident 20: August 6, (YEAR), resident reported she fell in her room, with complaints of wrist pain September 29, (YEAR), staff found the resident on the floor in her room and she sustained a hematoma to the right side of her head November 15, (YEAR), staff found the resident on the floor in her room November 21, (YEAR), the resident reported she fell in her room December 27, (YEAR), staff found the resident on the floor in her room and she sustained a [MEDICAL CONDITION] right arm A significant change MDS completed on (MONTH) 2, 2019, revealed Resident 20 was assessed as needing extensive assistance of two plus persons for bed mobility, transfers, and toilet use, had only walked in her room or corridor once or twice in the assessment period, required extensive assist of one person for dressing and hygiene, and limited assistance of one person physical assist for eating. In an interview with the Director of Nursing on (MONTH) 24, 2019, at 11:52 AM she confirmed the decline in Resident 20's bed mobility, transfers, toilet use, walking, dressing, hygiene, and eating were a result of the fracture the resident sustained [REDACTED]. Review of Resident 20's plan of care revealed the resident's falls care plan goal (to be free from serious injury) was not revised until (MONTH) 15, 2019, after the resident had five falls with one resulting in a fracture to the upper right arm. There were no new or revised interventions on the resident's falls plan of care since (MONTH) 4, (YEAR) until (MONTH) 1, 2019 after the resident had five falls/incidents. Resident 20 continued to have 10 more falls on the following dates: (MONTH) 1, 3, 7 (2 incidents), and 13, 2019; (MONTH) 4 and 12, 2019; (MONTH) 8 and 24, 2019; and (MONTH) 18, 2019. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on (MONTH) 24, 2019, at 11:52 AM. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 6/29/18 28 Pa. Code 201.18(b)(1) Management Previously cited 6/23/17 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 6/29/18 and 6/23/17

Based on review of select facility policies, clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to review and revise the plans of care to meet the physical needs of the resident for one of 12 residents reviewed (Resident 20). Findings include: Review of the facility policy entitled Falls Prevention, last reviewed on (MONTH) 26, 2019, revealed the facility's goal was to maintain the resident's environment as free from fall hazards while providing adequate support for the resident. The licensed nurse is responsible to implement appropriate interventions immediately after the fall based on the identified cause and the resident's care plan will be updated at the time the intervention is placed. Clinical record review for Resident 20 revealed the resident was admitted to the facility on (MONTH) 26, (YEAR). Review of Resident 20's plan of care revealed a falls care plan initiated on (MONTH) 26, (YEAR), (admission), which indicated the resident had a history of [REDACTED]. Review of facility fall investigations revealed the following for Resident 20: August 6, (YEAR), resident reported she fell in her room, with complaints of wrist pain September 29, (YEAR), staff found the resident on the floor in her room and she sustained a hematoma to the right side of her head November 15, (YEAR), staff found the resident on the floor in her room November 21, (YEAR), the resident reported she fell in her room December 27, (YEAR), staff found the resident on the floor in her room and she sustained a [MEDICAL CONDITION] right arm Review of facility investigations revealed that Resident 20 continued to have falls on (MONTH) 1, 3, 7 (2 incidents), and 13, 2019; (MONTH) 4 and 12, 2019; (MONTH) 8 and 24, 2019; and (MONTH) 18, 2019. The facility investigations dated (MONTH) 15, (YEAR), and (MONTH) 21, (YEAR), indicated Resident 20's care plan was reviewed and revised as an immediate action taken in response to the falls. Further review of Resident 20's plan of care revealed the resident's falls care plan goal (to be free from serious injury) was not revised until (MONTH) 15, 2019, after the resident had five falls with one resulting in a fracture to the upper right arm. There were no new or revised interventions on the resident's falls plan of care since (MONTH) 4, (YEAR) until (MONTH) 1, 2019 after the resident had five falls/incidents. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on (MONTH) 24, 2019, at 11:52 AM. 483.21(b) Care Plan Timing and Revision Previously cited 6/29/18 28 Pa. Code 211.11(d) Resident care plan Previously cited 6/29/18

Based on clinical record review and staff interview, it was determined that the facility failed to implement a comprehensive plan of care for one of 13 residents reviewed (Resident 1). Findings include: Clinical record review for Resident 1 revealed that on (MONTH) 15, 2019, her physician ordered Oxygen 2 liters per minute (LPM) via nasal canula (NC, a device used to deliver supplemental oxygen) for SpO2 (pulse oxygenation, the amount of Oxygen in the bloodstream) less than or equal to 89 percent room air (RA) every shift for decreased SpO2. There was no documentation that the facility implemented an Oxygen care plan for Resident 1 Interview on (MONTH) 23, 2019, at 2:00 PM with the Nursing Home Administrator and the Director of Nursing confirmed the above findings. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Previously cited 6/29/18

Based on clinical record review and staff interview, it was determined that the facility failed to complete a significant change Minimum Data Set assessment for one of 15 residents reviewed (Resident 25). Findings include: Interview with the Director of Nursing on (MONTH) 27, at 10:10 AM confirmed that the facility follows the guidelines from the Centers for Medicare and Medicaid's (CMS) Resident Assessment Instruction (RAI) for completing the Minimum Data Set (MDS, an assessment tool utilized to determine resident care needs). Review of the Resident Assessment Instrument 3.0 User's Manual (reference used to complete an MDS) revealed that the facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. Clinical record review for Resident 25 revealed an initial MDS assessment with an assessment reference date of (MONTH) 21, (YEAR), that indicated Resident 25 required extensive assistance (resident involved in activity, but staff provide weight-bearing support) for bed mobility, transfer, and toilet use, locomotion off unit, dressing, and personal hygiene. Review of Resident 25's quarterly MDS assessment with an ARD date of (MONTH) 24, (YEAR), revealed that she improved to supervision level with bed mobility, and that she improved to independent level (resident performed the activity without staff weight bearing support) with transfers, locomotion off unit, dressing, toilet use, and personal hygiene. Review of the RAI revealed that staff should complete a significant change MDS when a resident has a decline or improvement that will not normally resolve itself without interventions by staff, impacts more than one area of the resident's health status, and requires interdisciplinary review and or revision of the care plan. Interview with the Director of Nursing and Nursing Home Administrator on (MONTH) 28, (YEAR), at 10:10 AM confirmed that a significant change MDS should have been completed. 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 6/23/17

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to honor advance directive choices for one of one residents reviewed (Resident 94). Findings include: Review of the facility policy entitled, Advance Directive, last reviewed on (MONTH) 14, (YEAR), without changes, revealed that the resident has the right to formulate an advance directive. Upon admission, the facility will identify if the resident has an advance directive. The facility will identify the primary decision-maker for residents assessed as unable to make relevant health care decisions. All advance directive document copies will be obtained and located in the resident's medical record. Residents will be assessed periodically for decision-making ability capacity and for changes in resident preferences and choices. The interdisciplinary team will identify, clarify, and review, as part of the comprehensive care planning process, the existing care instructions along with the resident's goals or wishes. Clinical record review for Resident 94 revealed that the facility admitted her on (MONTH) 19, (YEAR), with physician orders indicating that she is not capable of understanding her rights and responsibilities and that staff are to perform cardiopulmonary resuscitation (CPR) should the need arise. On (MONTH) 19, (YEAR), at 4:17 PM social service indicated that she had met with Resident 94's spouse and daughters on several occasions throughout the past year to discuss resident's physical and cognitive status, especially in relation to her persistent memory loss. (Resident 94) has executed an advance directive and copies are placed on the medical chart. Though it was determined that Resident 94 was not capable, review of the facility's advance directive acknowledgement form (a form indicating a resident or responsible party's acknowledgement of an advance directive and implementing of such directive) dated (MONTH) 19, (YEAR), revealed that Resident 94 initialed and signed the form acknowledging she had an advanced directive, that she was executing the directive, and a copy was located in her medical record for facility use in case of a medical emergency. Review of Resident 94's current advance health care directive revealed that when Resident 94 lacks the ability to understand, make, or communicate a choice regarding a health care decision as verified by my attending physician, she requests that her health care agent ask her physician to issue a do not resuscitate (DNR) order including an out of hospital DNR order. On (MONTH) 25, (YEAR), social services completed a cognitive assessment, noting that Resident 94 scored 11 out of 15 on BIMS (Brief Interview for Mental Status, assessment that scores a resident's response to memory questions; a score of eight to12 indicates moderate impairment), which is indicative of her short term cognitive impairments. Resident 94 was able to repeat three of three words initially after social worker, however only recalled one of three at the end of the interview. On (MONTH) 27, (YEAR), the physician ordered that Resident 94 be a DNR. Until identified by the surveyor, the facility continued to have a physician's order indicating that Resident 94 would receive CPR should the need arise, though it had been determined upon admission that Resident 94 was not capable of making decisions and an advance directive noting DNR status was identified. On (MONTH) 28, (YEAR), at 10:57 AM the Director of Nursing confirmed the above findings. 28 Pa. Code 201.29(d) Resident rights 28 Pa. Code 211.10(a) Resident care policies Previously cited [DATE] 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited [DATE]

Based on clinical record review and interviews with residents and staff, it was determined that the facility failed to involve a resident in the care plan process for one of one residents reviewed (Resident 35). Findings include: Interview with Resident 35 on (MONTH) 26, (YEAR), at 10:40 AM revealed that the resident stated, I don't recall being invited, when asked about their participation in care plan meetings. Immediately following the interview, the Nursing Home Administrator entered Resident 35's room and the resident voiced an interest in attending care plan conferences to the Nursing Home Administrator. Clinical record review for Resident 35's Care Plan Conference Summaries dated (MONTH) 20, (YEAR), and (MONTH) 12, (YEAR), revealed Resident 35's representative and a family member attended the care plan conferences and the resident was not in attendance due to being incapable of attending. Review of current physician orders [REDACTED]. Review of an annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated (MONTH) 6, (YEAR), and a quarterly MDS assessment dated (MONTH) 6, (YEAR), revealed that staff assessed Resident 35 as having a BIMS score of 11 (BIMS, Brief Interview for Mental Status, assessment that scores a resident's response to memory questions; a score of 8-12 indicates moderate cognitive impairment). The facility was unable to provide documentation indicating why Resident 35 was incapable of being involved in the care plan conferences. Interview with the Nursing Home Administrator on (MONTH) 29, (YEAR), at 9:20 AM confirmed the above findings. 28 Pa. Code 211.11(d) Resident care plan Previously cited 6/23/17

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility's bed hold policy at the time of transfer for two of two residents reviewed for hospitalization s (Residents 10 and 42). Findings include: The facility policy entitled Bed Hold and Return to Facility, last reviewed by the facility on (MONTH) 14, (YEAR), revealed that residents who are transferred to the hospital or go on therapeutic leave are provided with written information about the bed hold duration and payment amount before transfer. Clinical record review revealed that Resident 10 was admitted to the hospital on (MONTH) 29, and (MONTH) 6, (YEAR). There was no documentation available that the facility provided written notice regarding a bed hold to the resident and/or the resident's responsible party upon transfer to the hospital. Interview with the Nursing Home Administrator on (MONTH) 28, (YEAR), at 2:00 PM confirmed that the facility had no process to supply residents, or their responsible parties, written notification of the facility's bed hold policy upon transfer. Clinical record review for Resident 42 revealed that she was transferred to the hospital on (MONTH) 14, (YEAR), after she had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and/or the resident's responsible party upon transfer to the hospital. Interview on (MONTH) 28, (YEAR), at 10:50 AM, with the Director of Nursing confirmed the above findings. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(f) Resident rights

Based on clinical record review, review of select facility policies, and staff interview, it was determined that the facility failed to implement measures to prevent accidents for two of 10 sampled residents (Residents CR1 and 25). Findings include: The facility policy entitled "Fall Prevention and Management" last reviewed on April 15, 2011, revealed that the staff will make every effort to prevent resident falls. At the time of a resident's admission to the skilled nursing unit, the Registered Nurse Assessment Coordinator or Charge Nurse completes a "Fall Risk Assessment." If the risk assessment score is moderate or severe or if in the judgment of the health care team, a resident is at risk for falls, the nursing staff will write a potential for falls care plan. The staff completes the "Fall Risk Assessment" at least every 90 days and as needed. Clinical record review for Resident 25 revealed "Fall Risk Assessments" dated August 5 and November 2, 2010, indicating that she was at a significant risk for falls. The facility implemented a plan of care indicating that Resident 25 was at risk for falls due to poor safety awareness, a past pelvic fracture due to a fall, gait dysfunction, and medication side effects. The staff was to avoid taking Resident 25 to her room until staff is available to assist her to use the toilet and lay in bed since she is prone to attempt to perform these tasks without assist. A review of Resident 25's clinical record revealed nursing documentation dated January 25, 2011, indicating that the staff responded to her alarm and found her lying on her left side on the floor in the doorway of her room next to her wheelchair. The facility investigation into the accident revealed that the therapeutic recreation intern took the resident to her room via a wheelchair. The therapeutic recreation intern left the resident in her room alone and reported her location to the Licensed Practical Nurse in charge and a nurse aide. A Registered Nurse Supervisor overheard the conversation and revealed that the staff should take the resident to a supervised area. Five to 10 minutes later, the resident's alarm sounded and the staff found her on the floor. Staff assisted Resident 25 to stand and found that she was unable to bare weight on her left leg and was complaining of pain in her groin area. An x-ray showed an acute sub capital fracture of the left hip. An interview with the Director of Nursing on June 29, 2011, at 9:30 AM confirmed that the staff left Resident 25 in her room unattended resulting in a fall causing a fracture of her left hip. Closed clinical record review for Resident CR1 revealed that the facility admitted him on February 3, 2011, with a [DIAGNOSES REDACTED]. A review of the "Fall Risk Assessment" dated February 3, 2011, indicated that he was at significant risk for falls. The facility implemented a plan of care indicating Resident CR1's need for the extensive assistance of two for toileting. Nursing documentation dated April 25, 2011, revealed that a nurse aide assisted Resident CR1 to the floor resulting in a 1.5 inch long by 0.5 inch wide bruise to his left posterior forearm. The facility investigation into the incident revealed that a nurse aide attempted to transfer Resident CR1 from his wheelchair to the toilet without assistance. Resident CR1 thought he was positioned over the toilet and he started to lower himself between the wheelchair and the toilet. The nurse aide lowered him to the floor. An interview with the Director of Nursing on July 1, 2011, at 11:30 AM confirmed that Resident CR1 required the assistance of two for transfer. A nurse aide attempted to transfer Resident CR1 by herself resulting in her lowering him to the floor. 483.25(h) Accidents. Previously cited 6/30/10 and 9/14/10 28 Pa. Code 211.10(d) Resident care policies. Previously cited 6/30/10 and 9/14/10 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 6/30/10 and 9/14/10