Every finding on record at Garden Spot Village

Based on clinical records review and staff interviews, it was determined the facility failed to implement an intervention to prevent a wound on the foot of a resident identified as high risk for skin impairment. The facility also failed to initiate a wound treatment, which resulted in actual harm of the wound worsening and getting infected for one of the two residents reviewed (Resident CL1).Findings include: Review of Resident CL1's demographic sheet revealed the resident was admitted to the facility on [DATE], post amputation of the right foot toe. The resident had diagnoses of Diabetes (group of metabolic disorders characterized by high blood sugar level over a prolonged period of time) and Peripheral Vascular Disease (PVD -circulatory condition that affects blood vessels outside the heart and brain, particularly in the legs and arms).Review of Resident CL1's care plan revealed interventions were developed on September 15, 2025, indicating resident was at risk for skin issues due to decreased mobility, edema (swelling), and circulatory issues.Review of Resident CL1's admission Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents), dated September 21, 2025, revealed the resident's cognition was intact. The same MDS assessment revealed resident was independent while rolling in bed, left to right.Review of Resident CL1's nursing progress notes revealed an entry dated September 27, 2025, at 11:07 p.m., indicating a small amount of blood was noted by Resident CL1's daughter on the resident's left foot sock after assisting the resident to bed and removing the shoes. A small skin tear was noted on (the resident's) left foot pinky toe. Area measured 1.0 x 0.5 cm (centimeters). The area was cleansed with NSS (sterile salt water) and covered with a band aid. Fax placed in CRNP (Certified Registered Nurse Practitioner) binder to note. TX (treatment) placed in TAR (Treatment Administration Record).Review of the nursing progress, weekly skin check note dated September 28, 2025, at 10:18 p.m., revealed treatment to the left foot. The same note revealed New interventions: Heel Boots.Review of Resident CL1's clinical records failed to reveal the new intervention, heel boots, was added to the resident's care plan. Further review of the clinical records failed to reveal the new intervention, heel boots, was implemented by the facility until October 4, 2025, as evidenced by a Weekly Skin Check Note dated October 4, 2025, at 9:26 p.m. indicating New Intervention: Heel Boots.Additional review of Resident CL1's progress notes revealed a Health Status note dated October 6, 2025, at 9:35 p.m., indicating LPN (Licensed Practical Nurse) called RN (Registered Nurse) to room to report a new opened area on resident's lateral (side) left foot. Area with opened area measuring 4.2x1.8x0.1cm with 25% granulation (new tissue), 25% epithelial (skin), and 50% thin layer of yellow slough (dead) tissue. Edges are intact with some peeling skin along edges. Periwound (tissue surrounding the wound) skin intact, edematous (swollen), and with ecchymosis (bruising) along dorsal (upper) edge. Resident reporting that area is due to abrasion (superficial injury caused by rubbing or scraping) from when lying in bed. Resident with air mattress with hanger over footboard of bed and reporting hitting it.Review of Resident CL1's October MAR revealed the left lateral foot was not treated from October 6, 2025, till October 8, 2025. The wound was treated with Medihoney (dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns) on October 8, 2025, two days after it was initially identified on October 6, 2025.Further review of the Progress Notes revealed a Secure Conversation dated October 9, 2025, at 2:26 p.m., indicating the resident with worsening abrasion on the left lateral foot with increasing redness and warmth to the dorsal foot. The wound base is now with 50% yellow/tan slough tissue with hypergranulation (excessive growth of red granulation tissue that sits above the wound's skin level, usually caused by excessive moisture, infection, or irritation) on the dorsal edge of the wound. The resident reports less tenderness to the area, but the area appears more inflamed (reddened, warm, and swollen), and drainage has also increased to moderate to heavy serous (clear). The wound treatment was changed to Silver Alginate (dressing used for moderate to heavy exuding wounds to help control infection and promote a wound environment for healing).Review of the Nurse Practitioner (NP) notes revealed an entry dated October 10, 2025, indicating the resident had an abrasion on the left foot that occurred when the foot rubbed on the footboard of the bed, as stated by the resident. Staff noted that the area was extremely erythematous (abnormal redness of the skin due to accumulation of blood in the area) yesterday, with concerns over possible infection. Today, the erythema of the foot has improved, but still very tender to touch. The resident was diagnosed with left foot cellulitis (skin infection that causes a red, painful, and swollen area of skin, which is commonly caused by Staphylococcus bacteria that enter the body through a cut or break in the skin). The wound care treatment was changed, and Doxycycline (an antibiotic) by mouth was ordered by the NP.Interview with licensed nurse Employee E2 on November 13, 2025, at 12:40 p.m., revealed the facility utilizes a kind of heel boot that covers the entire foot of the resident. Employee E2 was unable to provide documented evidence the facility consistently implemented the heel boot intervention to protect Resident CL1's feet from developing further skin impairment.An interview with the NHA (Nursing Home Administrator) on November 13, 2025, at 2:00 p.m., was conducted. The NHA confirmed there was no documented evidence the heel boot intervention to protect Resident CL1's feet from further skin impairment were implemented. The NHA also confirmed a wound treatment on Resident CL1's left lateral foot was not completed on October 6, 2025, and October 7, 2025.The facility failed to implement Resident CL1's heel boot intervention to prevent further skin impairment and failed to provide wound care to a wound abrasion, which resulted in actual harm when the wound deteriorated and became infected. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing servicesPreviously cited 1/5/24 28 Pa Code 211.5(f) Clinical RecordsPreviously cited 1/5/24

Based upon review of staffing records and inservice documentation, it was determined the facility failed to ensure nurse aides received required 12-hour annual re-training for one of five records reviewed. Findings Include: Review of five staffing records and inservice documentation revealed four nurse aides received the required 12-hour annual retraining. Further review of the staffing records and inservice documentation revealed one of the five records reviewed failed to reveal evidence of 12-hour annual retraining. Interview with the Nursing Home Administrator on December 13, 2024, at 10:00 a.m. confirmed one nurse aide did not complete the required 12-hour annual retraining within the appropriate timeframe. 28 Pa. Code 201.20(a)(c) Staff Development

Based on review of facility policy and clinical record review, it was determined that the facility failed to follow physician's orders and timely notify the physician of a significant change in condition for one of 18 residents reviewed, resulting in actual harm of Hypoxia (the body is deprived of adequate oxygen supply at the tissue level) for Resident 8. Findings include: Review of facility policy, Notification of Condition Changes, last revised April 19, 2023, revealed the facility would notify the resident's provider when there is a significant change in the resident's condition, abnormal test results, and/or a need to alter treatment significantly. Review of Resident 8's physician's orders revealed an order dated November 20, 2023, for oxygen 3 liters (L) nasal cannula every shift for shortness of breath and hypoxia (low oxygen levels). The order further stated that nursing may titrate (adjust) oxygen to keep the resident's oxygen saturation above 90%. Review of Resident 8's progress notes revealed a nursing note dated November 20, 2023, (6:00 p.m.) which indicated: Resident's o2 [(oxygen)] read 78 [(normal is 95-100)] and resident refused to wear oxygen cannula. After dinner, resident's o2 read 57 and continue to refuse to wear cannula. Resident was convinced to wear it but stated she will remove it shortly. Additional review of Resident 8's clinical record failed to reveal any documented evidence the physician was notified of the resident's low oxygen saturation levels or the resident refusing to wear the oxygen cannula. There was no documented evidence that the facility attempted to titrate the resident's oxygen to maintain a level above 90%. Further review of Resident 8' progress notes revealed a nurse's note dated November 21, 2023, at 5:03 a.m. which indicated: Resident's [pulse oximetry] was 87% with o2 at 2L. Resident refused [head of bed] to be raised. Staff continues to educate resident about the [pulse oximetry] level she should be at and how to achieve that goal. Resident has audible wheezing and is [short of breath.] Will continue to follow plan of care. Further review of Resident 8's clinical record failed to reveal documented evidence the physician was notified of the resident's low oxygen saturation levels, wheezing, or shortness of breath. There was no documented evidence that the facility attempted to titrate the resident's oxygen to maintain a level above 90%. Review of Resident 8's clinical record revealed a nurse's note on November 22, 2023, at 5:46 a.m. which indicated: Resident found sitting in recliner leaning to the left with eyes closed without o2 cannula. At this position resident [pulse oximetry] was 67%. Resident difficult to arouse. When applying o2 cannula, [pulse oximetry] increased to 87% on 2L o2. A few minutes later resident woke up gasping with [shortness of breath,] frantic, and confused. Gave resident education about leaving o2 cannula on and explanation. Resident agreed to leave it on. Will continue to follow plan of care. Review of Resident 8's clinical record failed to reveal documented evidence the physician was notified of the resident's low oxygen saturation levels or shortness of breath. There was no evidence that the facility attempted to titrate the resident's oxygen to maintain a level above 90%. Further review of Resident 8's progress notes revealed a nurse's note on November 23, 2023, at 5:27 a.m. which stated: Resident lying in bed [pulse oximetry] was 65%. When [Resident 8] sat on the side of bed [pulse oximetry] increased to 83%. Resident was encouraged to take deep breaths and cough but no further improvement. Review of Resident 8's clinical record failed to reveal documented evidence the physician was notified of the resident's low oxygen saturation levels or shortness of breath. There was no evidence that the facility attempted to titrate the resident's oxygen to maintain a level above 90%. Further review of Resident 8's progress notes revealed a nurse's note on November 23, 2023, at 11:25 a.m. which stated: Resident away from home with family for thanksgiving dinner and left facility at 11:25. Resident's pulse ox was 83% on 3L of o2 via [nasal cannula.] Review of Resident 8's clinical record failed to reveal documented evidence the physician was notified of the resident's low oxygen saturation levels or shortness of breath. There was no evidence that the facility attempted to titrate the resident's oxygen to maintain a level above 90%. Further review of Resident 8's progress notes revealed a nurse's note date November 23, 2023, at 10:20 p.m. which indicated: Resident's o2 fluctuated throughout the shift. At one time it read 49% when returning from an outing with family. After o2 cannula placed on resident, [his/her] o2 raised to 84%. When checked at [bedtime,] resident's o2 read at 72%. Resident appears to only be mouth breathing and cannula is not being used correctly. Resident removes cannula periodically when left alone. Resident is reminded to breathe through nose. Review of Resident 8's clinical record failed to reveal documented evidence the physician was notified of the resident's low oxygen saturation levels or shortness of breath. There was no evidence that the facility attempted to titrate the resident's oxygen to maintain a level above 90%. Further review of Resident 8's progress notes revealed a nursing note dated November 24, 2023, at 5:00 a.m. which indicated: Resident noted using abdominal muscles for breathing and experiencing air hunger (difficulty breathing). Unable to raise oxygen saturation more than 83% @3L. The on-call [physician] gave orders to send the resident to [emergency room ] for eval. Review of Resident 8's hospital discharge summary revealed the resident was hospitalized in the intensive care unit (ICU) from November 24, 2023 until December 3, 2023, with a diagnosis of acute respiratory failure with hypoxia and hypercapnia (high levels of carbon dioxide) and required BiPAP (machine that normalizes breathing by delivering pressurized air via face mask into the upper airway that leads to the lungs. Its bilevel design means that a BiPAP device provides two different levels of air pressure: one for breathing in and one for breathing out.) The facility's failure to follow Resident 8's physician's orders for oxygen at 3 liters and titrating to maintain oxygen levels above 90% as well as the failure to timely notify the physician of Resident 8's change in condition was discussed with the Nursing Home Administrator and Director of Nursing on January 5, 2023, at approximately 10:40 a.m. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa Code 211.5(f) Clinical Records 28 PA Code 211.10(a) Resident care policies

Based on clinical record review and staff interview it was determined the facility failed to complete accurate assessments for one of 24 residents reviewed. (Resident 70) Findings Include: Review of Resident 70's clinical record inclusding progress notes revealed a nursing entry dated October 27, 2023 indicating Resident 70 went home with all of his belongings and medications. Review of Resident 70's discharge Minimum Data Set (MDS- periodic assessment of resident needs) dated October 27, 2023 revealed the assessment was coded as Resident 70 being discharged to a hospital. Interview with Licensed Nursing Employee E3 on January 5, 2023 at 10:00 a.m. confirmed Resident 70's discharge MDS of October 27, 2023 should have been coded as the resident being discharged to home not to a hospital. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on review of clinical record and review of documentation provided by the facility to the State Agency, it was determined that the facility failed to report an allegation of physical abuse to the State Agency for one of 19 residents reviewed (Resident #43). Findings include: Review of Resident #43's [DIAGNOSES REDACTED]. Review of Resident #43's progress notes dated (MONTH) 23, 2019 at 10:45 p.m. revealed while doing skin assessment this shift a bruise was noted on residents right hand measuring 8.5 centimeters (cm) x 6.5 cm. Resident stated that it happened during (morning) care and CNA grabbed (resident's) arm while assisting (resident) which resulted in bruising later. Denies pain. Review of investigation documentation dated (MONTH) 24, 2019 revealed that the allegation of abuse was unsubstantiated by the facility after completion of the investigation. Interview with the Director of Nursing on (MONTH) 10, 2019 at approximately 10:00 a.m. revealed that the facility failed to report the allegation of physical abuse to the State Agency as required. 28 Pa. Code 201.14(a)(c) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(d) Management

Based on observations, clinical record review and staff interview, it was determined that the facility failed to follow the manufacturer's professional parameters for the administration of a diabetic medication for one of 15 residents reviewed (Resident C18). Findings include: As per the [MEDICATION NAME]® manufacturer ' s medication insert for professionals, revised date February 2015, [MEDICATION NAME]® should generally be given immediately (within 5-10 minutes) prior to the start of a meal. Review of Resident C18 ' s current [DIAGNOSES REDACTED]. physician order, dated May 1, 2016, revealed an order for [REDACTED]. During the medication pass observation, on May 23, 2016, at 10:05 a.m., licensed nursing staff, Employee E4 took Resident C18's blood glucose level. The resident blood sugar level was recorded at 264. Based on the sliding scale coverage (amount of insulin administered according to the guidelines calculated) ordered by the physician, Employee E4 administered 11 units of [MEDICATION NAME]to Resident C18. Continued observation of Resident C18 revealed resident sitting at the breakfast dining table, at 10:15 a.m. waiting for breakfast to be served. Resident C18 was not served breakfast until 10:45 a.m. There was a 30 minute delay between Resident C18 receiving the insulin, and eating breakfast. Interview with the Director of Nurses, on May 24, 2016 at approximately 11:30 a.m., confirmed that the physician order [REDACTED]. 28 Pa. Code: 201.14(a) Responsibility of licensee Previously cited 5/22/2014 28 Pa. Code:211.5(f) Clinical records Previously cited 5/22/2014 28 Pa. Code: 211.10(c) Resident care policies Previously cited 5/22/2014 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services Previously cited 5/22/2014

Based on staff and resident interview and review of facility documentation, it was determined the facility failed to provide activities to meet the needs of the residents during evening and weekend hours for one of 15 residents reviewed. (Resident E5) Findings Include: Interview with Resident E5 on May 24, 2016 at 10:00 a.m. revealed there were no activities provided after supper or on the weekends. Review of facility activities calendars for March, 2016 revealed there were no evening recreation staff on 18 of 31 days in the month and church was the only activity provided on three of the four Sundays. Review of the facility activity calendars for April 2016 revealed there were no evening recreation staff on 13 of 30 days. Review of facility activity calendars for the month of May 2016 revealed there were no evening recreation staff 18 out of 31 days. Interview with Employee E3 on May 25, 2015 at 1:30 p.m. revealed the staff who usually provided the evening activities were needed to train newly hired employees and unable to both provide activities and train the new employees for the last three months. Employee E3 confirmed that there were no evening and weekend activities on these day for the months of March, April, and May 2016 due to therapeutic recreation staff being utilized for training of newly hired employees. F248 483.15(f)(1) Activities 28 Pa. Code: 201.18(b)(3)(e)(6) Management 28 Pa. Code: 201.29(j) Resident rights

Based on a Review of the POS [REDACTED]. Findings include: The position description of the Nursing Home Administrator indicated that the purpose of the position is to maintain established standards and practices and operate the facility in accordance with the established policies and procedures of the governing body in compliance with federal, state and local regulations. The Nursing Home Administrator is to observe all facility safety policies and procedures. The position description of the Director of Nursing indicated that the purpose of the position is to provide nursing management, set resident care standards for all direct care providers and prove complete supervision and management for the nursing department. The Director of Nursing is to identify safety hazards and initiate corrective action and is to be responsible for the safety of residents under his/her care or supervision. The deficiency cited under the Code of Federal Regulatory Groups for Long Term Care, Quality of Care, F323, 483.25(h)(1) and (2) Accidents and Supervision, revealed that the Nursing Home Administrator and the Director of Nursing failed to ensure that the Country Kitchen in the Springwood Unit was secure to restrict access to residents and failed to ensure that adequate supervision was provided at the steam table in that unit, which had six dementia residents, placing the health and safety of the residents in Immediate Jeopardy. Refer to F323. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 05/22/14. 28 Pa. Code 201.18(b)(1) Management. Previously cited 02/25/15, 05/22/14 28 Pa. Code 201.18(b)(3)(4) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 02/25/15 28 Pa. Code 211.12(c) Nursing services. Previously cited 02/25/15, 05/22/14 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 02/25/15, 05/22/14, 06/05/13

Based on observations, facility documentation, clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the serving area in one of the four Country Kitchens (Springwood Household) was adequately secured to restrict access to potential hazards and to ensure the safety and supervision of residents with dementia living in the Springwood Household, placing the residents in an Immediate Jeopardy situation. Findings include: Observation of the Springwood Household on July 1, 2015, at approximately 1:00 p.m., revealed a dining area and a Country Kitchen that was in the living area of Springwood Household. The Country Kitchen has a bar style counter around the Country Kitchen that opens into the dining area. The Country Kitchen furnishings included a steam table with two steam wells, a stove, a refrigerator/freezer, a dishwasher, a coffee pot, storage cabinets and storage drawers for cooking and serving equipment and cleaning supplies. The cleaning supplies were locked in a cabinet. The preparation and serving area within the Country Kitchen was not secured by a gate or other device, but was open to residents and staff who could walk into the preparation and serving area. Homemaker, Employee E3, was observed at this time serving the midday meal to the residents. On July 1, 2015, at 1:20 p.m., Homemaker, Employee E3 was observed leaving the Springwood Country Kitchen area unattended. Steam was observed pouring out of the two steam table wells. The wells were under clear plastic covers that covered the steam wells. Employee E3 called out to nursing staff, Employee E7, who was in the area, to watch the area. Nursing staff, Employee E7, did not acknowledge the homemaker and left the area to assist a resident. Employee E3 was observed taking pans containing left over food items and soiled utensils from the Springwood Country Kitchen to the main kitchen. Employee E3 returned to the Country Kitchen at 1:25 p.m. Employee E3 left the Springwood Country Kitchen unattended for a period of 5 minutes (1:20 p.m.-1:25 p.m.). Employee E3 was observed to remain in the kitchen area on July 1, 2015, until 2:30 p.m., at which time she left the area. No nursing staff or other homemaker staff was observed in the Springwood Country Kitchen living area from 2:30 p.m. to 3:00 p.m. The steam tables were observed to be bubbling with steam during this time while the Springwood Country Kitchen was unattended. Homemaker, Employee E4, was observed in the Springwood Country Kitchen at 3:00 p.m. Interview with Employee E4 on July 1, 2015, at 3:30 p.m., in the Springwood Country Kitchen, confirmed that the steam table wells were left turned on when Employee E4 came into the kitchen area at 3:00 p.m. Employee E4 revealed that Employee E3 had left the Country Kitchen at 2:30 p.m., which was the end of her shift. The Springwood Country Kitchen was observed by the survey team to be left unattended for thirty minutes on July 1, 2015, from 2:30 p.m. to 3:00 p.m. Further observation of the Country Kitchen on July 1, 2015, at 3:30 p.m., revealed that water in the two steam table wells was steaming and bubbling. Two individual thermostat controls were observed in a cabinet underneath the steam table. These thermostat controls regulated the temperature of the two steam table wells. The thermostat control dials went from a setting of 1 to 10 with 10 being the highest temperature setting. The thermostat controls were observed to be set at eight. The water temperature in the steam table was tested on [DATE], at 4:45 p.m., in the company of Employee E4 and registered at 180 degrees Fahrenheit. During the initial tour of Springwood Household on July 1, 2015, at approximately 12:30 p.m., accompanied by Licensed Nurse, Employee E8, it was revealed through interview with Employee E8 that 16 residents resided on the Springwood Household and six residents were identified with a [DIAGNOSES REDACTED]. Although no residents were observed as unattended or wandering on July 1, 2015, from 1:20 p.m. through 3:00 p.m., the preparation and serving area of the Springwood Country Kitchen had two steam tables filled with water that were turned on and the water temperature registered at 180 degrees Fahrenheit when tested at 4:45 p.m. There was the potential for residents to wander into the area unsupervised while steam table water wells were left turned on and unattended and equipment that was not secured. Review of the Resident Census and Condition sheet for Springwood Household received on July 1, 2015, and revised on July 2, 2015, revealed 16 residents resided on the unit and nine out of 16 residents had the [DIAGNOSES REDACTED]. Resident E5's quarterly MDS assessment dated [DATE], related the resident had a Brief Interview Mental Status (BIMS) score of 2, indicating severely cognitively impaired. (BIMS scores range from 0 to 15 with 15 being cognitively intact and scores of 0 to 7 indicate severely impaired cognition and scores of 8 to 12 indicate moderately cognitively impaired.) Resident E7's quarterly MDS assessment dated [DATE], related the resident had a BIMS score of 4, indicating severely cognitively impaired. Resident E8's quarterly MDS assessment dated [DATE], related the resident had a BIMS score of 9, indicating moderately cognitively impaired for decision making. Resident E10's comprehensive MDS assessment dated [DATE], related the resident had a BIMS score of 8, indicating moderately impaired cognition for decision making. Resident E13's quarterly MDS assessment dated [DATE], related the resident had a BIMS score of 3, indicating severe cognitive impairment. Resident E15's admission MDS assessment dated [DATE], related the resident had a BIMS score of 3, indicating severe cognitive impairment. Immediate Jeopardy was identified on July 1, 2015, at 4:20 p.m. for failing to ensure that one Country Kitchen serving area, in the Springwood Household, was safely secured, supervised and restricted from resident access when steam tables were turned on, which placed the health and safety of residents in Immediate Jeopardy. An action plan was requested on July 1, 2015, at 4:20 p.m, to immediately put systems in place to provide adequate supervision of the Country Kitchen serving area in the Springwood Household, to ensure the safety of the residents. The action plan provided by the facility of July 1, 2015 included for all homemaker staff to be inserviced by the Nursing Home Administrator prior to the end of their shift on July 1, 2015, and the on coming staff to be inserviced prior to the start of the shift of the facility's policy, Safe practices in the Household Kitchen indicating that, when the steam table is on, the kitchen should be attended by staff. The Nursing Home Administrator and Household Coordinators were to monitor the kitchen for compliance on a dally basis and for staff failing to follow the facility's policy to be disciplined. Review of the facility's written policy, undated, received on July 1, 2015, at approximately 4:45 p.m., stated that the Country Kitchens are staffed from 6:30 a.m. to 6:30 p.m. An interview with Employee E5, the Household Coordinator, on July 2, 2015, at 9:30 a.m., revealed that homemakers would go to the Country Kitchens and turn on the steam wells in the steam tables at 6:30 a.m., and then return to the main kitchen to bring food and supplies to the Country Kitchen. The interview also revealed that the homemakers are not to leave the area unsupervised and should ask another staff person to cover the area in their absence. Review of the revised policy titled, Safe Practices in the Household Kitchen, revised July 2, 2015, related the following: a. Turn the steam table on after AM pickup in the kitchen. b. Turn off and drain the steam table after the noon meal. Turn off the heat and allow the water to cool for 10-15 minutes prior to draining. c. Steam table to be refilled for the evening meal, after the homemaker has made their p.m. pickup in the kitchen. d. Steam table to be turned off and drained appropriately as soon as evening meal is complete to allow for cooling while the homemaker is still in the kitchen. The Immediate Jeopardy was removed on July 2, 2015, at 1:10 p.m., following the implementation of an acceptable plan of action. All staff including licensed nurses and nursing assistants were re-educated regarding the need for supervision in the Country Kitchen areas when steam tables are turned on or not completely cooled. Observation of the Country Kitchen on July 1, 2015, at 3:30 p.m., revealed a lighter lying loose in a unsecured drawer next to the kitchen sink, which was accessible to the residents. Interview with the Nursing Home Administrator (NHA) on July 1, 2015, at approximately 3:45 p.m., indicated the lighter was used to light the grill on the outside patio. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 02/25/15, 05/22/14 28 Pa. Code 201.18 (b)(1) Management. previously cited 02/25/15, 05/22/14 28 Pa. Code 201.18(e)(1) Management. Previously cited 02/25/15 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 207.2(a) Administrator's responsibility. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 02/25/15, 05/22/14, 06/15/13

Based on a review of clinical records and staff interview, it was determined that the facility failed to provide a behavior monitoring tool with noted behaviors to be evaluated during the use of antidepressants and antipsychotic medications for four of 15 residents reviewed (Resident E1, E5, F2 and F9). Findings include: Review of Resident E1's physician's orders [REDACTED]. Further review of Resident E1's behavior tracking record for March 2015 and April 2015, revealed that the facility failed to state what behaviors were exhibited for monitoring. Review of Resident E5's physician's orders [REDACTED]. Review of Resident F2's May 2015, physician's orders [REDACTED].½ tab twice a day for anxiety, and [MEDICATION NAME] 100 milligrams (an anti-depressant medication) daily. Review of Resident F2's behavior tracking record for the months of December 2014 through May 2015, completed for each medication revealed no documentation of the behaviors being monitored as it was directed in the behavior tracking form. Review of Resident F9's June 2015, physician's orders [REDACTED].½ tab as needed for anxiety. Review of Resident F9's behavior tracking record for June 2015, completed for each medication revealed no documentation of the behaviors being monitored as it was directed in the behavior tracking form. During an interview with the Director of Nursing and the Nursing Home Administrator on July 6, 2015, at approximately 2:00 p.m., it was confirmed that the facility failed to address the documentation of targeted behaviors on resident's behavior tracking records. 42 CFR 483.75(l)(1) Resident Records-Complete/Accurate/Accessible. Previously cited 05/22/14 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 05/22/14 28 Pa. Code 211.5(f) Clinical records. Previously cited 02/25/15, 05/22/14, 06/05/13 28 Pa. Code 211.10(c) Resident care policies. Previously cited 05/22/14, 06/05/13 28 Pa. Code 211.10(d) Resident care policies. Previously cited 02/25/15, 05/22/14, 06/15/13 28 Pa. Code 211.12(c) Nursing services. Previously cited 02/25/15, 05/22/14 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 02/25/15, 05/22/14, 06/05/13

Based on a review of clinical records and a staff interview, it was determined that the facility failed to develop plans of care for residents who displayed psychosocial needs for two of 15 residents reviewed (Residents E15 and F2). Findings include: Review of Resident E15's admission Minimum Data Set assessment (MDS- a periodic assessment of resident care needs) Care Area Assessment Summary (documentation of care areas triggered by the MDS to be addressed in the resident's care plan), dated June 12, 2015, revealed that the resident triggered for a care plan for psychosocial needs and indicated that a plan of care would be initiated with interventions. Review of Resident E15's current plan of care revealed no documented evidence that a care plan was developed to address the psychosocial needs of this resident. Interview with the Director of Nursing on July 6, 2015, at approximately 2:45 p.m., confirmed the aforementioned finding. Review of Resident F2's clinical record revealed behavior notes for March 22, 2015, May 6, 2015, and May 7, 2015, indicating that the resident was making statements of, I want to die or, I wish I was dead. Review of the resident's current plan of care revealed that there was no plan of care in place and there were no interventions developed to address the resident's statements regarding these verbalizations. 42 CFR 483.20(d) Develop Comprehensive Care Plans. Previously cited 06/05/13 28 Pa Code 211.5(f) Clinical records. Previously cited 02/25/15, 05/22/14, 06/05/13 28 Pa. Code 211.11(d) Resident care plan. Previously cited 06/15/13 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 02/25/15, 05/22/14, 06/05/13

Based on the clinical record review, staff interview and review of the facility policy, it was determined that the facility failed to obtain an informed consent from the resident's legal surrogate or representative to exercise the right based on information that would have been provided to the resident for the use of a restraint for one of 15 residents reviewed (Resident F2). Findings include: Review of the facility's policy titled, Restraint last revised on September 26, 2001, revealed that the responsible party was to be notified of the decision for the use of a restraint for the resident and to obtain a signature on the Physical Restraint Consent Form. Review of Resident F2's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Physical Restraint Consent Form dated December 16, 2014, revealed that this form indicated Resident F2's potential risks and potential benefits of the use of a Merry Walker (a device that contains a seat with an enclosed gate on the front of the seat, allowing for the individual to ambulate holding the bar on the front of the seat). The Merry Walker was documented as the type of restraint to be utilized for Resident F2. The facility obtained a verbal consent from Resident F2's daughter for the use of a Merry Walker and on December 17, 2014, a signature was obtained from the resident's daughter consenting to the use of the Merry Walker for Resident F2 and to acknowledge that she has been fully informed of the risk and benefits related to the use of the Merry Walker. Review of the Durable General Power of Attorney documentation in the resident's clinical record revealed that the resident's son was the designated individual to act as the resident's Power of Attorney (provides written authorization to represent or act on another's behalf), not the resident's daughter. There was no evidence that the facility discussed the potential risks and potential benefits of the use of the Merry Walker with the son, who was the resident's Power of Attorney, as it was indicated in the facility's policy. Interview with the Nursing Home Administrator on July 2, 2015, at approximately 11:15 a.m., confirmed there was no documented evidence that the facility contacted the resident's Power of Attorney to obtain an informed consent for the use of this restraint. 28 Pa. Code 201.14(b) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. Previously cited 02/25/15, 05/22/14

Based on clinical record review, and resident and staff interviews, it was determined that the facility failed to establish clear advanced directives, completion of the POLST (Pennsylvania Orders for Life Sustaining Treatment form) for two of 15 resident records reviewed (Residents F2 and F6). Findings include: Review of Resident F2's admission records revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's, Pennsylvania Orders for Life Sustaining Treatment Form ( POLST-a document that informs emergency treatments the resident wants, and doesn't want, in case of a medical emergency), completed and signed on December 3, 2014, by the resident's daughter, indicated that the daughter was the resident's health care agent (a legal determination who can make financial and/or healthcare decisions for a person who cannot make their own decisions due to some kind of incapacitation). Review of the, Durable General Power of Attorney documented in the resident's clinical record, revealed that the resident's son was the designated individual to act as the resident's Power of Attorney (provides written authorization to represent or act on another's behalf). There was no evidence that the facility had discussed with the son, who was the designated Power of Attorney for the resident, indicating that the resident's daughter could sign the POLST form. Interview with the Nursing Home Administrator on July 2, 2015, at approximately 11:15 a.m., confirmed there was no documented evidence maintained in the facility appointing the daughter as the medical surrogate or Power of Attorney for Resident F2. Review of Resident F6's admission records revealed that the resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. does not receive enough blood and oxygen), [MEDICAL CONDITION] Stage III and [MEDICAL CONDITION] (a reduction in red blood cells). Review of the resident's admission Minimum Data Set assessment (MDS- a periodic assessment of resident care needs) completed on February 3, 2015, related that the resident had a BIMS (Brief Interview Mental Status Assessment -assessment utilize to determine the resident cognitive level) score of 15, which indicted that the resident was cognitively intact. During an interview with Resident F6 on July 2, 2015, at approximately 11:55 a.m., the resident stated that during his stay at the hospital, the resident had formulated a living will (a written statement detailing a person's desires regarding their medical treatment in circumstances in which they are no longer able to express informed consent) and thought a copy of the living will was on his clinical record. Review of Resident F6's clinical record revealed no evidence of a copy of the resident's living will or that the POLST form was completed with the resident. The facility failed to obtain documentation on the resident's living will and failed to ensure the completion of the POLST form. 28 Pa. Code 201.18(b)(1) Management. Previously cited 02/25/15, 05/22/14 28 Pa. Code 211.5(f) Clinical records. Previously cited 02/25/15, 05/22/14, 06/05/13 28 Pa. Code 211.10(a) Resident care policies. Previously cited 02/25/15 28 Pa. Code 211.10(d) Resident care policies. Previously cited 02/25/15, 05/22/14, 06/15/13

Based on a review of the facility policy and observation during the environmental tour of the physical therapy department, it was determined that the facility failed to maintain the [MEDICATION NAME] (water bath for heating pads) unit in a sanitary manner. Findings include: Review of the facility's policy titled, [MEDICATION NAME] Cleaning, no date provided, revealed that all [MEDICATION NAME] units will be cleaned monthly and that the monthly cleaning will be recorded in a log including the month and date of the cleaning and the signature of the staff completing the cleaning. Observation conducted of the [MEDICATION NAME] unit cleaning log on July 6, 2015, at approximately 12:00 p.m., during an environmental tour of the physical therapy department, accompanied by the Nursing Home Administrator, revealed no documented evidence that the [MEDICATION NAME] unit was cleaned during the months of April 2015 and May 2015. An interview with the therapy department staff, Employee E6, at the time of the observation confirmed that the [MEDICATION NAME] unit had not been cleaned during the above stated months. The facility failed to follow their policy regarding the cleaning of the [MEDICATION NAME]. 28 Pa. Code 201.18(b)(1) Management. Previously cited 02/25/15, 05/22/14 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on observation, clinical record review, resident and staff interview and review of facility's policy, it was determined that the facility failed to assess a resident after a fall incident, to complete a neurological assessment and failed to clarify physician's orders [REDACTED]. (Resident A1). Findings include: Review of facility's policy title Incident and Accident Prevention and Investigation, revised April 5, 2012 revealed under the following procedures: " #4- Should incident occur, the resident will receive an assessment by a licensed nurse immediately and treatment administered as deemed appropriate. #6 If a fall was not witnessed and a resident was not able to tell if he hit his head or not and there was no evidence of head injury, neurochecks were to be completed every 15 minutes x 4 to rule out signs and symptoms of head injury. If it is known that the resident hit his head, the neuro checks would be completed every 15 minutes x 4, every 30 minutes (340 minutes typo in policy) x 2 and every 60 minutes x 2. The results of the neurochecks were to be record on the vital sign sheet." #10 Non- fall incidents such as but not limited to bruises and skin tears/abrasions will be assessed and proper treatment applied. The family and physician will be notified. The supervisor will be notified and as assessment will be done immediately to verify that reasonable cause can be established for the injury. The non-fall incident report and reasonable cause/intervention form will be completed by the end of the shift. " Review of Resident A1 February, 2015 physician's orders [REDACTED]. Review of the resident's admission Minimum Data Set (MDS- assessment of resident status and care needs) dated January 27, 2015 identified the resident with no cognitive impairments, requiring limited assistance of one person for transferring, supervision for ambulation in the room, extensive assistance of one person for hygiene and occasionally incontinence of bladder. The resident balance during transition and walking was assessed as not steady when moving from a seated to standing position, walking, moving on and off toilet and from surface to surface. Review of Resident A1 ' s fall assessment completed on January 20, 2015 identified the resident with a score of 14 which placed the resident at high risk for falls. Review of nursing documentation dated February 1, 2015 at 2:00 p.m. indicated that the resident's grand-daughter notified nursing staff that the resident stated that she had a fall during the previous evening. The resident was noted to have a bruise on her forehead described as yellow-bluish and discolored. Review of the facility fall investigation report dated February 1, 2015, documented that the resident stated to the family member that during the previous evening she got up from bed alone with the use of her walker to go to the bathroom. Once in the bathroom she lost her balance and fell . The resident stated that she struggle to get up and returned to her bed. Further review of the fall investigation report revealed that the nursing assistant noted a bruise on the resident's forehead during morning care and notified the charge nurse. Review of nursing notes on February 1, 2015 revealed no documented evidence that licensed staff completed an assessment of Resident A1 at the time that the nursing assistant notified the licensed nursing staff of the bruise found on the resident's forehead. The facility failed to promptly assess Resident A1 after the licensed nursing staff was notified of the bruise noted on the resident's head. Review of weekly skin assessment documentation dated February 4, 2015 at 7:50 p.m. noted bruising to the right side of the resident's face, right arm and great toe from the fall of February 1, 2015. There was no documented evidence that a full body assessment was completed on Resident A1 from February 1, 2015 until February 4, 2015 (3 days later) after the fall incident to assess for further injuries as a result of the fall that occurred during the evening/night of February 1, 2015. Observation and interview conducted on February 24, 2015 at 12:30 p.m. of Resident A1 in the dining area revealed that a small discolored bruise on top of the resident's right eye brown. The resident stated during interview that the bruise occurred when she fell in the bathroom. Further review of Resident A1 ' s clinical record revealed that a neurological assessment was initiated on February 1, 2015 at 3:30 p.m. and the next neurological assessment was done during the 3-11 nursing tour of duty; however, no specific time was documented and no other neurological assessment was completed on Resident A1. Interview conducted with licensed nurse, Employee E3 on February 24, 2015 at 12:30 p.m. confirmed that the neurological assessment was not fully completed. The facility failed to completed neurological assessments as indicated on their facility's policy for a resident who was known to have hit her head during a fall incident. Review of Resident A1 February 2015 physician's orders [REDACTED]. On January 23, 2015 at 9:04 a.m. it was noted that the resident again was administered 3 liters per minute of oxygen. On January 26, 2015 at 11:06 a.m. it was documented that the resident was on 3 liters of oxygen via nasal cannula and staff could not get an oxygen saturation level on room air. Review of February 2015 Medication Administration Record [REDACTED]. On February 11, 12, 13, 18, and 2015 the resident was administered 2.5 litters of oxygen. Interview conducted with licensed nurse, Employee E3 on February 24, 2015 at 12:30 p.m. confirmed that the physician order [REDACTED]. The facility failed to clarify the physician's orders [REDACTED]. F309 Quality of Care Previously cited 5/22/14 28 Pa Code: 201.18(b)(1)(e)(1) Management Previously cited 5/22/14 28 Pa Code: 211.5(f) Clinical records Previously cited 5/22/14 28 Pa Code: 211.10(d) Resident care policies Previously cited 5/22/14 28 Pa. Code: 211.12(c)(d)(1)(5) Nursing services Previously cited 5/22/14

Based on a review of clinical records, staff interview and review of facility's policy, it was determined that the facility failed to thoroughly complete investigations into fall incidents sustained by two of two residents reviewed (Resident A1 and A2) to ensure adequate supervision and development of interventions to prevent falls for Resident A2 and failed to ensure that residents equipment was firmly secure to prevent accidents. Findings include: Review of facility's policy title Incident and Accident Prevention and Investigation, revised April 5, 2012 revealed under the following procedures: "#8 the supervisor will be notified of the fall and the interventions reviewed and updated on the plan of care. #9 the incident report and fall intervention forms will be completed by the end of the shift." Review of Resident A1 February, 2015 physician's orders [REDACTED]. Review of the resident's admission Minimum Data Set (MDS- assessment of resident status and care needs) dated January 27, 2015 identified the resident with no cognitive impairments, requiring limited assistance of one person for transferring, supervision for ambulation in the room, extensive assistance of one person for hygiene and occasionally incontinence of bladder. The resident balance during transition and walking was assessed as not steady when moving from a seated to standing position, walking, moving on and off toilet and from surface to surface. Review of nursing documentation dated February 1, 2015 at 2:00 p.m. indicated that the resident's grand-daughter notified nursing staff that the resident stated that she had a fall during the previous evening. The resident was noted to have a bruise on her forehead described as yellow-bluish and discolored. Review of the post fall investigation report revealed that an investigation was initiated and a statement was obtained from the resident as to the events of the fall incident. The report stated that the nursing assistant noted a bruise on the resident in the morning during morning care and reported it to the charge nurse. There was no documented evidence that the facility further investigated the fall incident by obtaining statements from the nursing assistant who discovered the bruise on the resident, the licensed nursing licensed staff who was notified of the bruise on the resident's forehead and nursing personnel present during the evening/night shift of January 1, 2015. Interview with the director of nursing (DON) on February 25, 2015 at 1:05 p.m. confirmed that no written statements were obtained from nursing staffs who cared for the resident and only the nursing supervisor was verbally interviewed. Review of the facility fall investigation report for Resident A1 dated February 1, 2015 documented that during resident interview, the resident stated that during the evening of February 1, 2015 she got up from bed alone with the use of a walker to go to the bathroom. Once in the bathroom she lost her balance and fell . The resident stated that she struggle to get up and returned to her bed. Observations conducted on January 25, 2014 at 9:30 a.m. and 1:30 p.m. of the resident's bathroom revealed that a portable commode was placed on top of the toilet seat. The commode was not permanently affix to the wall or toilet and was light in weight and could be tipped over easily. Interview with the director of nursing (DON) on February 25, 2015 at 3:30 p.m. confirmed that the portable commode was the device use to raise the level of the toilet seat for Resident A1. There was no evidence that the facility had assessed Resident A1 safety in the use of the portable commode place on top of the toilet after the fall incident sustained by the resident on February 1, 2014 in the bathroom to ensure the resident safety. Review of Resident A2 February 2015 physician's orders [REDACTED]. Review of the significant change Minimum Data Set (-assessment of resident care needs and status) completed on December 9, 2015 identified the resident with moderate cognitive impairment and requiring extensive assistance with transferring with one person assist. The resident ambulated in her room and the corridor only one or two times during the assessment observation period. Review of fall assessment completed on December 10, 2015 identified the resident at high risk for falls. Review of Resident A2 ' s current plan of care revealed that the resident was at risk for falls due to a past history of falls which resulted in injury, weakness, ambulatory dysfunction, pain, and [DIAGNOSES REDACTED]. and wheel chair in reach or in sight, to make sure that the wheelchair was locked, and to check resident every hour around the clock. Review of nursing documentation revealed that Resident A2 sustained five falls between December 7, 2014 and January 25, 2015 as follows: -On December 7, 2015 at 3:33 p.m. it was noted that the nursing assistance entered the room a few minutes after exiting and found Resident A2 out of her recliner. The resident had fallen on the floor. -On December 19, 2015 at 8:15 p.m. the nursing assistant noted that the resident was sitting on the recliner foot rest with chair tipped forward and the resident left upper body resting on the floor. The resident left shoulder was red with a brush burn. -On January 6, 2015 at 10:15 p.m. the resident was found by nursing staff sitting on the floor between the wall and the recliner. Bruising was noted on the resident ' s left wrist. -On January 10, 2015 at 6:30PM. The resident was found on the floor on the left side in front of the closet. The resident was noted with a bruise and an abrasion on the right eye, the bridge of the nose and above the right lip and right knee. -On January 25, 2015 at 7:00 p.m. the resident was found on the floor laying on the right side with her back into the recliner. Review of Resident A2 ' s post fall investigation reports to the above stated falls revealed that there was no statements obtained of nursing staff who provided care or observed the resident during the 3-11 evening shift at the time of the falls. Further review of the fall investigation reports to the falls on December 7, 2014, December 19, 2014, January 6, 2015, January 10, 2015 and January 25, 2015 indicated to continue current intervention listed on the plan of care. There was no evidence that new safety measures were initiated to assist and prevent the resident from further falls as stated in the facility's policy. Observation conducted on February 25, 2014 at 9:35 a.m. revealed that Resident A2 was seated on the recliner in her room. A second observation of the resident at approximately 1:30 p.m. revealed that the resident was observed in her room standing in front of the reclining chair facing the door way. Approximately 15 seconds later a loud noise was heard from the resident's room and the nursing assistant was summoned to the room. The resident had fallen between the reclining chair and the closet. The nursing assistant was observed picking up the resident from the floor and seated the resident back into the wheelchair to be assessed by licensed nursing staff. The facility failed to put into place increased measures to adequately monitor and supervise Resident A2 while in the chair to prevent multiple falls from occurring. F323 483.25(h) Free of Accident Hazards/Supervision/ Devices Previously cited 5/22/14 28 Pa Code: 201.18(b)(1)(e)(1) Management Previously cited 5/22/14 28 Pa Code: 211.5(f) Clinical records Previously cited 5/22/14 28 Pa Code: 211.10(a) Resident care policies 28 Pa Code: 211.10(d) Resident care policies Previously cited 5/22/14 28 Pa Code: 211.12(c)(d)(1)(3)((5) Nursing services Previously cited 5/22/14

Based on observation, review of facility policy, review of clinical records and interview with staff, it was determined that the facility failed to provide the necessary care to prevent the development of a pressure area causing actual harm to one of 15 residents reviewed. (Resident A17). Findings include: Review of the facility's " Skin Care Protocol " revised May 13, 2005, indicated that the facility had a policy for the prevention of skin destruction for residents who were fully or partially immobilized and were determined to be at risk for skin breakdown. The policy stated that an assessment would be conducted on admission to determine the risk of impairment including risk factors that may exist for each resident. The policy indicated that a prevention guideline would include the elevation of heels off the bed and consider the use of heel protectors. Review of Resident A17 ' s [DIAGNOSES REDACTED]. the foot causing pain). Review of Resident A17 ' s admission nursing assessment dated [DATE] revealed that the resident scored an " 8 " for risk in the skin assessment section which indicated a high risk for skin breakdown. No open areas were identified on admission on the resident ' s feet by the admitting professional staff. The resident ' s admission MDS assessment (assessment of the resident ' s care needs and status) dated April 9, 2014 revealed in Section M that the resident was at risk for pressure ulcer development. The assessment also indicated that the resident required the limited assistance of one person to move in bed. Review of Resident A17 ' s nursing progress note dated May 10, 2014 stated that a bolster and heel protectors were being used secondary to an open area on the right heel. Review of the " Wound and Pressure Sore Identification and Progress Record " revealed a wound identified on May 10, 2014 on the right heel which measured 1 centimeter by 1 centimeter by 0.2 centimeters deep. The professional nurse , Employee E8 documented the stage of the wound as a stage III and this is identified in the facility Skin Care Protocol as full thickness skin loss involving damage or necrosis of the subcutaneous tissue which may extend down to but not through the fascia; the ulcer presents clinically as a deep crater. Employee E8 also documented that the wound was covered 100% with slough (devitalized white or yellow tissue that adheres to the ulcer bed in clumps or strings which inhibits healing) with a small amount of drainage. Review of the nursing progress notes dated May 11, 2014 revealed that there was a yellow slough filled crater on the right outer heel. The note further stated that the area was in contact with the footrest although not in contact with the splint worn for plantar fasciitis. In addition, the note stated that staff were to be educated on relieving pressure by off-loading the resident's heels. Review of Resident A17 ' s care plan revealed that the facility did not develop interventions to reduce pressure on the resident ' s heels until May 10, 2014, the day the wound was identified. An interview with Employee E4, the unit manager on May 22, 2014 at approximately 9:30 a.m. confirmed that Resident A17 ' s care plan was not updated with interventions to reduce heel pressure until the stage III ulcer on the right heel was identified on May 10, 2014. The facility failed to develop and implement a plan of care per facility policy to off load Resident A17s heels who was assessed at risk for pressure ulcer development and who required assistance with repositioning resulting in the development of a Stage III right heel ulcer and actual harm to Resident A17. 28 Pa. Code: 211.5(f) Clinical records Previously cited 6/05/2013 28 Pa. Code: 211.10(d) Resident care policies Previously cited 6/05/2013 28 Pa. Code: 211.10(d)(1)(5) Nursing services Previously cited 6/05/2013 and 5/24/2012

Based on review of facility policy, review of clinical records, interviews with residents and staff, it was determined that the facility failed to conduct interdisciplinary assessments for the evaluation of a resident's ability to safely administer medication for two of 15 residents reviewed (Residents C16 and G8). Findings include: Review of facility policy, Self-Administration of Medication, effective date December 2009, indicated that residents are offered the opportunity to self-administer medications and permitted to do so if the practice would be safe for the resident and other residents in the facility. Procedure Steps B and C indicated for those residents who request to self administer medications, an assessment would be conducted by the interdisciplinary team of the resident's cognitive, physical and visual ability and by means of a skill assessment conducted on a quarterly basis. Skill Sets 1-3 refer to the preparation and instruction in the oral route of administration. Skill Set 4 directs staff to verbalize the steps involved in administration of a nonsolid dosage form such as an inhaler. Finally, procedure Step D included for the results of the assessment to be recorded in the resident's medical record. A resident group interview was conducted, on May 21, 2014 at 10:15 a.m., eight residents attended. During this group interview, two residents, Resident C16 and F3, both revealed that they were self administering nasal spray medication and eye drop medications. Review of Resident C16's clinical record revealed that resident was admitted to facility on April 15, 2014. Resident C16's current care plan report, dated May 16, 2014, indicated that resident wanted to self administer medications, and that resident was comfortable with self administration of eye drops without needing further instruction. Review of Resident C16's May 2014 Medication Administration Record [REDACTED]. Review of Resident C16's nurse note, dated May 16, 2014 at 9:00 a.m., entitled Preparation for Self Medication RN assessment indicated that the resident requested for the self administration of artificial tears (relief of dry eyes), [MEDICATION NAME] (sleep aide); [MEDICATION NAME] (regulates flow of fluid in eye to maintain pressure) eye drops [MEDICATION NAME] spray (congestion relief). Further review of this assessment, dated May 16, 2014, failed to provide evidence that Resident C16 was assessed for all those skill levels required for the preparation and instilling of an ophthalmic (eye) and nasal medications; and failed to include a physician order [REDACTED]. Review of Resident C16's physician orders, revealed that resident was ordered, on May 20, 2014, for the independent administration and keep at bedside the following medications: [REDACTED]. Review of Resident G8's current medication orders, revealed an order, dated February 17, 2014, for resident to be administered Saline (salt solution treats dry or irritated nasal passages) nasal spray, instill four drops into nostrils twice daily. Review of Resident G8's current care plan report, dated February 17, 2014, for problem areas of allergic rhinitis (inflammation of nasal passages revealed that the resident was to keep the saline nasal spray at bedside as per the physican and would use as needed as per the physician order. Interview with Resident G8, accompanied by licensed Employee E4, on May 22, 2014 at 12:00 p.m., confirmed that resident self administers saline nasal spray and that licensed staff are aware. Interview with licensed Employee E3, on May 22, 2014 at 12:10 p.m., confirmed that Resident G8 self administers saline nasal spray. Licensed Employee E4 further confirmed, on May 22, 2014 at approximately 2:00 p.m., that Resident G8 was self administering the saline nasal spray without a physician order [REDACTED]. Facility failed to update and further develop a self administration policy in regard to a framework for both determining and assessing basic, competency skill levels required for those dosage forms which include topical, inhaled. ophthalmic and nasal administration; and failed to include a physician order [REDACTED]. 28 Pa. Code: 201.18(a)(b)(1) Management 28 Pa. Code: 211.5(f) Clinical records Previously cited 6/05/2013 28 Pa. Code: 211.10(c) Resident care policies Previously cited 6/05/2013 28 Pa. Code: 211.12(c) Nursing services 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 6/05/2013

Based on review of facility policies and procedures, clinical record review, facility documentation and staff interviews, it was determined that the facility failed to conduct a thorough investigation for bruises of unknown origin for one of 15 residents reviewed (Resident E13). Findings include: Facility policy entitled, "Policy and Procedure for Abuse Prohibition-Prevention of Abuse" revised on June 6, 2003, indicated that the facility will provide a safe and secure environment for it's residents. The facility will investigate and determine the cause of any bruises/injuries of unknown origin that are discovered on a resident. The investigation will utilize the facility incident report to investigate and determine causal factors. If it is determined that the bruise/injury was caused by an abusive act, the facility will investigate and report as prescribed in policy. Review of Resident E13's clinical record containing a Physician Fax/Order Sheet dated May 5, 2014 revealed daughter would like Resident E13 to be examined by physician. Daughter feels mother might have fallen and may have a fracture. Noticed a bruise on her left hand, left mouth and lip. Also noticed tremors. A review of Resident E13's Physician's Progress Note dated May 5, 2014 under section Assessment/Plan/[DIAGNOSES REDACTED]. Interview with Director of Nursing on May 21, 2014 at approximately 12:40 p.m. confirmed after checking with Nursing Home Administrator an incident report had not been completed. There was no investigation of the bruises to determine the causal factors. Interview with licensed nurse, Employee E7 on May 22, 2014 at 2:30 p.m. confirmed that Resident E13 had been examined and assessed by the Certified Nurse Practioner on May 5, 2014. The facility failed to follow their policy to investigate and determine the cause of bruises of unknown origin. 28 Pa. Code: 201.29 (a)(c)(d) Resident rights. 28 Pa. Code: 211.5 (f) Clinical records. Previously cited 6/05/2013 28 Pa. Code: 211.5(g) Clinical records. 28 Pa. Code: 211.10 (c)(d) Resident care policies. Previously cited 6/05/2013

Based on review of clinical record and staff interviews, it was determined that the facility failed to follow physician's orders for medication administration and treatments for two of 15 residents reviewed (Residents A9 and E7). Findings include: Review of Resident A9's physician orders dated November 27, 2013 revealed that the resident was to have TED hose ([MEDICAL CONDITION] deterrent stockings) applied in the morning and taken off at bedtime. This was documented by the physician to address circulation issues. An observation on May 20, 2014 at the supper meal revealed that the resident did not have his TED stockings on. On May 21, 2014 at 10:30 a.m. the resident was observed in the dining room in a wheelchair without the TED hose on. The licensed nurse, Employee E8 confirmed that the resident did not have the stockings on as ordered by the physician. Review of Resident E7's physician's orders dated March 29, 2014 revealed an order for [REDACTED]. During medication pass observation on May 21, 2014 at 9:40 a.m. Resident E7 was observed sitting in wheelchair in the country kitchen, completely dressed and well groomed awaiting breakfast. A licensed nurse, Employee E9 was observed administering medication to Resident E7, which included the [MEDICATION NAME]. Interview with licensed nurse, Employee E9 on May 22, 2014 at 11:05 a.m., confirmed that physician's orders were not followed and Resident E7 should have received [MEDICATION NAME] prior to receiving morning care. 483.25 Quality of Care Previously cited 6/05/13 28 Pa. Code: 211.5 (f) Clinical records. Previously cited 6/05/13 28 Pa. Code: 211.10 (c) Resident care policies. Previously cited 6/05/13 28 Pa. Code: 211.12 (d)(1)(5) Nursing services. Previously cited 6/05/13