Every finding on record at Gardens at York Terrace, The

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to adequately monitor and assess weight loss for one of three sampled residents at risk for weight loss. (Resident 5) Findings include: Review of the facility policy entitled, Weight Assessment and Intervention, last reviewed January 18, 2024, revealed that any weight change of five pounds (lbs.) or more from the last weight assessment would be retaken for confirmation. If the weight was verified, nursing staff would notify the dietitian. The dietitian or Certified Dietary Manager would review the individual weight records and make recommendations as appropriate. Clinical record review revealed that Resident 5 had diagnoses that included osteoporosis and dementia. Review of the care plan revealed that the resident had a history of weight loss. On March 1, 2024, the resident weighed 127 lbs. On April 5, 2024, the resident weighed 117 lbs. The resident was reweighed on April 7, 2024, and weighed 120 lbs., which verified a weight loss of 7 lbs., (5.5 percent). There was a lack of evidence to support that staff notified the dietitian, or that the dietitian assessed the weight loss or resident's nutritional status until April 30, 2024, during a regularly scheduled quarterly assessment. In an interview on December 5, 2024, the Administrator confirmed that there was no evidence that the dietitian was notified of the verified weight loss and that the dietitian should have assessed the resident prior to April 30, 2024. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation and staff interview it was determined that the facility failed to store food under sanitary conditions in the kitchen. Findings include: Observation of the kitchen during a tour on January 3, 2024, at 10:00 a.m. revealed an opened container of thickener that was not labeled or dated, an opened bag of spaghetti that was undated, and a grilled cheese sandwich on the bottom shelf in the dry storage area. There was trash and food debris on the floor in the freezer. In an interview on January 3, 2024, at 10:20 a.m., Employee 1 confirmed that the opened items should have been dated and that the grilled cheese sandwich should have been discarded. 28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of 16 sampled residents. (Resident 10) Findings include: Clinical record review revealed that Resident 10 had diagnoses that included congestive heart failure, diabetes mellitus, dementia, and peripheral vascular disease. On November 20, 2023, the physician ordered that staff administer a medication (Lasix) if the resident gained more than three pounds in one day to treat the resident's swelling in her legs. Review of Resident 10's weights revealed that on December 7, 2023, Resident 10 weighed 134 pounds (lbs). On December 8, 2023, the resident weighed 145 lbs, indicating a nine pound weight gain. On December 15, 2023, the physician ordered for staff to weigh the resident three times a week and administer Lasix if the resident gained more than three pounds when weighed on Monday, Wednesday, or Friday. On December 25, 2023, the resident weighed 140 lbs and on December 27, 2023, she weighed 145 lbs, indicating a five pound weight gain. A review of the December 2023, Medication Administration Record revealed that there was no evidence that staff administer the Lasix as ordered on December 8, 2023, or December 27, 2023. In an interview on January 5, 2024, at 10:15 a.m., the Director of Nursing confirmed that Resident 10 did not receive the Lasix as ordered by the physician. 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 that proper catheter care was provided for one of two sampled residents who used an indwelling urinary catheter (a flexible tube that a clinician passes through the urethra and into the bladder to drain urine). (Resident 8) Findings include: Clinical record review revealed that Resident 8 had a physician's order dated January 7, 2023, for the use of an indwelling catheter for the diagnosis of urinary retention. Observations on January 19, 2023, from 12:15 p.m. through 1:33 p.m., revealed the resident was seated in a wheelchair with the Foley bag and tubing directly on the floor. In addition, Resident 8's care plan directed that staff place the catheter bag in a privacy bag. There was no privacy bag in use during the observation. During an interview on January 20, 2023, at 12:50 p.m., the Director of Nursing confirmed that the bag and tubing should not have been in contact with the floor and that a privacy bag was to be used. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and observation, it was determined that the facility failed to ensure that a call bell was accessible for one of 14 sampled residents. (Resident 6) Findings include: Clinical record review revealed that Resident 6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE], revealed the resident required extensive assistance from staff for activities of daily living, including bed mobility, personal hygeine, and toileting. Review of the current care plan revealed Resident 6 was at risk for falls and that he was to be encouraged to use the call bell which was to be kept within reach. On February 23, 2022, at 11:05 a.m., the resident was observed in bed with his call bell on the floor under his bedside table, next to his bed, and out of reach. On February 23, 2022, at 12:40 p.m., the resident was observed in his bed eating lunch with his bedside table over him. His call bell remained on the floor next to his bed out of reach. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of the facility policy, review of medication manufacturer's instructions, and observation it was determined that the facility failed to storage medication in accordance with facility policy in two of three medication carts. Findings include: Review of the facility policy and procedure entitled Medications Storage in the Facility dated January 21, 2021, revealed outdated medication were to be immediately removed from stock and disposed of according to procedures for medical disposal. Medication storage conditions were to be monitored on a continual basis. Observation of the Rainbow Unit medication cart on March 16, 2021, at 11:00 a.m., revealed two vials of [MEDICATION(S)] (insulin) and Novolog (insulin) with no expiration date. The manufacturer's instructions for the above medications stated that medications in use more than 28 days should discarded. There were three opened bottles of [MEDICATION(S)] (nasal spray) that had no opened or expiration date. The manufacturer's instructions stated that medication in use more than 6 months should be discarded. The cart also contained Breo (inhaler) that had no opened or expiration date. According to the manufacturer's instructions medication in use more than six weeks should be discarded. Observation of the Rosewood Unit medication cart on March 16, 2021, at 11:40 a.m., revealed [MEDICATION(S)] (inhaler) with no opened or expiration date. According to the manufacturer's instructions medication in use more than 30 days should be discarded. There was also [MEDICATION(S)] (inhaler) that had no opened or expiration date. The manufacturer's instructions stated that medication in use more than six weeks should be discarded. 28 Pa. code 211.9 (h)(i) Pharmacy services 28 Pa. code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to minimize the potential for diversion of controlled substances ([MEDICATION(S)] patch) for one of 15 sampled residents. (Resident 27) Findings include: Review of the facility policy entitled, Disposal of Medications and Medication-Related Supplies, dated January 21, 2021, revealed that when a controlled medication was destroyed, it was to be done in the presence of two licensed nurses, and the disposal was to be documented on the accountability record. Clinical record review revealed that Resident 27 had diagnoses that included [CONDITION(S)] and rotator cuff tear. On January 25, 2017, the physician ordered a [MEDICATION(S)] patch (a controlled substance patch) to be applied every third day for pain. Review of the medication administration records for January, February, and March 1 through 17, 2021, revealed that the [MEDICATION(S)] patch was applied and removed 26 times with no evidence that a second licensed nurse was present for the removal and destruction. In an interview on March 19, 2021, at 10:05 a.m., the Director of Nursing confirmed that there was no documentation to support that a second nurse was present for the removal and destruction of the [MEDICATION(S)] patches. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that pain was managed in accordance with facility policy for one of 15 sampled residents. (Resident 5) Findings include: Review of the facility policy entitled, Pain Assessment and Management, dated January 21, 2021, revealed that standardized pain assessment tools, such as a ten-point numeric pain rating scale (zero indicating no pain and ten indicating the worst pain imaginable), were to be used to assess a resident's pain and pain management interventions should reflect the sources, type, and severity of pain. Clinical record review revealed that Resident 5 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan indicated that she had pain related to a decline in condition. Narcotic pain medication (morphine) was ordered by the physican on October 25, 2020, for five milligrams (mg) every two hours as needed for pain. The resident also had a physician's order dated February 2, 2020, for a non-narcotic [MEDICATION(S)] suppository (Tylenol) 650 mg give every six hours as needed for pain. In addition, on January 22, 2021, the physician ordered Tylenol 650 mg give every four hours by mouth as needed for pain. Review of the medication administration records for January, February, and March 1 through 18, 2021, revealed that Resident 5 received the as needed narcotic 14 times for pain ranging from zero to eight on the pain scale. She also received the non-narcotic pain medication three times for pain ranging from zero to four. The physician's orders did not include parameters for the level of pain to direct administration of the as needed pain medications. There also was no documented evidence that nursing staff assessed the severity of the resident's pain before administering the pain medications. In an interview on March 19, 2021, at 10:00 a.m., the Director of Nursing confirmed that physician's orders did not include parameters for the administration of the as needed pain medications. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to provide medically-related social services to a resident requesting psycho-social supportive interventions for one of 18 sampled residents. (Resident 23) Findings include: Clinical record review revealed that Resident 23 had [DIAGNOSES REDACTED]. Nursing documentation dated (MONTH) 24, 2019, and (MONTH) 15, 2019, noted that the resident displayed periods of emotional distress, pain, and/or coping difficulty as evidenced by episodes such as yelling out, tearfulness, stating that she didn't want to be there, and the inability to be consoled. A nurse's note dated (MONTH) 21, 2019, at 4:01 p.m., indicated that Resident 23 requested to speak to someone about the end of life and that the resident was told that a staff member would visit her. It was also documented, Note left for Social Services staff. In an interview on (MONTH) 25, 2019, at 12:42 p.m., the Social Worker confirmed knowledge of the resident's request. However, there was a lack of documentation to support that staff had followed through to provide psycho-social interventions as requested by and promised to Resident 23. 28 Pa. Code 211.16(a) Social services.

Based on clinical record review and staff interview, it was determined that the facility failed to implement nutritional interventions to ensure that residents maintained stable weight and reassess the weight status for three of 18 sampled residents. (Resident 11, 40, 46) Findings include: Clinical record review revealed that Resident 11 had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated (MONTH) 8, 2019, identified that the resident had cognitive impairment and required a mechanically-altered diet texture. On (MONTH) 12, 2019, the resident weighed 150 pounds and on (MONTH) 2, 2019, the resident weighed 158 pounds, a gain of 8 pounds. On (MONTH) 3, 2019, the resident weighed 134 pounds and (MONTH) 2, 2019, the resident weighed 142 pounds, a weight gain of 8 pounds. There was no documentation to support that a reweigh was completed with in 24 hours. Clinical record review revealed that Resident 40 had [DIAGNOSES REDACTED]. A MDS assessment dated (MONTH) 27, 2019, identified that the resident had cognitive impairment and had weight gain. On (MONTH) 19, 2019, the resident weighed 118 pounds and on (MONTH) 18, 2019, the resident weighed 102 pounds, a loss of 16 pounds. On (MONTH) 2, 2019, the resident weighed 106 pounds and on (MONTH) 18, 2019, the resident weighed 97 pounds, a loss of 9 pounds. On (MONTH) 6, 2019, the resident weighed 100 pounds and on (MONTH) 19, 2019, the resident weighed 111 pounds or a weight change of five pounds or more. There was no documentation to support that a reweigh was completed with in 24 hours. Clinical record review revealed that Resident 46 had [DIAGNOSES REDACTED]. A MDS assessment dated (MONTH) 11, 2019, identified that the resident was cognitively impaired and required a therapeutic diet. On (MONTH) 3, (YEAR), the resident weighed 220 pounds and on (MONTH) 3, 2019, the resident weighed 215 pounds, a loss of 5 pounds. On (MONTH) 3, 2019 the resident weighed 223 pounds and on (MONTH) 2, 2019, the resident weighed 232 pounds, a weight gain of 9 pounds, There was no documentation to support that a reweigh was completed with in 24 hours. In an interview on (MONTH) 25, 2019, at 10:40 a.m., the Director of Nursing stated that resident reweighs had not been completed. 28 Pa. Code 211.12(d)(3) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet the current needs of two of 18 sampled residents. (Residents 11,40) Findings include: Clinical record review revealed that Resident 11 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated assessment dated (MONTH) 8, 2019, identified that the resident had cognitive impairment and required a mechanically-altered diet texture. Documentation revealed a nutrition progress note dated (MONTH) 2, 2019, indicating that the resident had a significant weight gain of 6% or 8 pounds in one month. There was no plan of care developed or interventions to address the problem area of nutrition. Clinical record review revealed that Resident 40 had a [DIAGNOSES REDACTED]. Review of a MDS assessment dated (MONTH) 11, 2019, revealed that the resident had been on a therapeutic diet. The Care Area Assessment (CAA) dated (MONTH) 11, 2019, indicated that the therapeutic diet was used as a nutrional approach to encourage diet compliance, and an individualized resident care plan was to be developed to address that need. There was no plan of care developed or interventions to address the problem area of nutrition. In an interview on (MONTH) 25, 2019, at 10:30 a.m., the Director of Nursing confirmed that there had been no plan of care developed with interventions to address the problem area of nutrition. 28 Pa. Code 211.11(d) Resident care plan

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed hold policy (an agreement for the facility to hold the a bed for an agreed rate during a hospitalization ) to the resident, family member or legal representative at the time of transfer for four of 17 sampled residents (Residents 11, 49, 50, 59). Findings include: Review of the facility's policy for bed hold information, last reviewed on (MONTH) (YEAR), revealed that the facility will provide written information to the resident or legally responsible party that specifies the bed hold policy prior or at the time of the transfer to a hospital or other anticipated temporary leave. Clinical record review revealed that Resident 11 was transferred and admitted to the hospital on (MONTH) 19, (YEAR), after a change in her condition. There was no documented evidence that the resident or responsible party was provided written information about the facility's bed hold policy at the time of transfer. Clinical record review revealed that Resident 49 was transferred and admitted to the hospital on (MONTH) 13, (YEAR), after a change in her condition. There was no documented evidence that the resident or responsible party was provided written information about the facility's bed hold policy at the time of transfer. Clinical record review revealed that Resident 50 was transferred and admitted to the hospital on (MONTH) 23, (YEAR), after a change in her condition. There was no documented evidence that the resident or responsible party was provided written information about the facility's bed hold policy at the time of transfer. Clinical record review revealed that Resident 59 was transferred and admitted to the hospital on (MONTH) 28, (YEAR), after a change in her condition. There was no documented evidence that the resident or responsible party was provided written information about the facility's bed hold policy at the time of transfer. In an interview, on (MONTH) 2, (YEAR), at 1:45 p.m., the Administrator confirmed that there was no documented evidence that the resident or responsible parties had been notified of the bed hold policy upon transfer for the aforementioned residents.

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement care plans and care planned interventions for three of 17 sampled residents (Residents 6, 48, and 52). Findings include: Clinical record review revealed that Resident 6 had [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS, an assessment completed at specific intervals to determine care needs) assessment dated (MONTH) 2, (YEAR), indicated that the resident was alert and oriented to self. The MDS required that Resident 6 had a one person physical assist for toileting. Resident 6 had a care plan that she was at risk for falls and required assistance with her activities of daily living. Review of the care plan intervention revealed that staff were to transfer the resident with a one person physical assist for toileting with her rolling walker. Review of an incident report revealed that on (MONTH) 6, (YEAR), Resident 6 was found by staff in the bathroom, sitting on the floor. A staff member had left her unattended in the bathroom. In an interview on (MONTH) 3, (YEAR), the Director of Nursing stated that staff should have followed her care plan and remained with her until toileting was complete. Clinical record review revealed that Resident 48 had [DIAGNOSES REDACTED]. The annual MDS assessment dated (MONTH) 3, (YEAR), indicated that the resident was alert and oriented. Review of an incident report revealed that on (MONTH) 9, (YEAR), Resident 48 hit a female resident's face twice. Review of an incident report revealed that on (MONTH) 16, (YEAR), the resident hit the same female resident on the arm. Resident 48 had a care plan that identified a problem area that he sometimes becomes frustrated with others. The clinical record revealed that after each of these incidents Resident 48's care plan was not reviewed or revised. In an interview on (MONTH) 3, (YEAR), the Director of Nursing confirmed that the care plan was not reviewed or revised. Clinical record review revealed that Resident 52 had [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated (MONTH) 30, (YEAR), indicated that the resident was alert and oriented, utilized pain medications as needed, and had constant pain in the last five days that rated an eight on a scale of one to 10. The Care Area Assessment Summary (CAA) for this MDS triggered on the area of pain and the decision was to proceed to the development of a care plan. Review of the resident's current plan of care revealed that there had not been a care plan developed as per the CAA with interventions to address the resident's constant pain. In an interview on (MONTH) 3, (YEAR), the Director of Nursing stated that there had not been a care plan developed to address pain in a timely manner. 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policy and observation, it was determined that the facility failed to ensure that medications in an emergency box were properly labeled and stored in one of two medication rooms (Rosewood medication room). Findings include: Review of the facility's policy entitled Storage of medications, dated (MONTH) 18, (YEAR), revealed that the medications were stored in the containers in which they were received. Transfer between containers was performed only by the issuing pharmacy. No discontinued, outdated or deteriorated medications were available for use in the facility. All such medications were to be destroyed. Drug containers that had soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels were to be relabeled before storing. Observation of the medication room on the Rosewood nursing unit on (MONTH) 1, (YEAR), at 10:45 a.m., revealed that there were eight emergency IV supply boxes maintained in the medication room available for resident use. Each box had an expiration date. Four of the IV supply boxes had expiration dates that ranged between (MONTH) and (MONTH) (YEAR). Observation on (MONTH) 1, (YEAR), at 10:45 a.m., and again on (MONTH) 2, (YEAR), at 1:20 p.m., in the same medication room, revealed a sealed unlabeled liquid bottle that was on the shelf with other stock medication supplies. 28 Pa. Code 211.12 (d)(1) Nursing services

Based on clinical record review and staff interview, it was determined that that the facility failed to thoroughly investigate an injury of origin to rule out potential abuse for one of ten sampled residents. (Resident R60) Findings include: Clinical record review revealed that Resident R60 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An initial Minimum Data Set assessment dated [DATE], identified that the resident had memory impairment, was dependent on staff to transfer and walk. An initial admission skin assessment on January 12, 2017, noted no abnormal areas to the resident's lower extremities. On January 16, 2017, a physician's physical examination noted that the resident had a lot of ecchymotic areas (discolored area on the skin or membrane caused by blood seeping into tissue as a result of a contusion) on the right lower leg. In an interview on May 17, 2017, at 3:15 p.m., the Director of Nursing was unable to provide evidence to support that the facility investigated possible causes of the ecchymotic areas to rule out abuse. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 8/18/16, 4/12/17

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented and followed for two of four sampled residents. (Resident R1, CL1) Findings include: Clinical record review revealed that Resident R1 had [DIAGNOSES REDACTED]. Review of a physician's note on March 3, 2017, revealed that the resident had lower extremity [MEDICAL CONDITION] with the chronic fluid retention and the physician changed the diuretic medication and ordered for a basic metabolic panel (BMP diagnostic lab test) to be completed on March 9, 2017. There was no documented evidence that the BMP was completed as ordered by the physician. In an interview on April 12, 2017, at 1:06 p.m., the Director of Nursing confirmed that the BMP had not been completed as ordered by the physician. Clinical record review revealed that Resident CL1 had [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] and was discharged from the facility on December 16, 2016. Review of a nurse's note dated July 29, 2016, at 3:27 p.m., revealed that a physician ordered to obtain a complete blood count (CBC diagnostic lab test) and a BMP every two months. There was no documented evidence that the CBC or BMP was completed as ordered by the physician between July 2016 and December 2016. In an interview on April 12, 2017, at 2:45 p.m., the Administrator confirmed that the diagnostic lab tests should have been completed in October 2016; however, the facility failed to obtain the lab tests as ordered by the physician. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited 8/18/16

Based on group interview and a review of resident council minutes, it was determined that the facility failed to ensure that an on-going grievance was acknowledged and resolved for three of six alert and oriented residents who attended the group meeting. (Residents R26, R46, R57) Findings include: During a group interview on August 17, 2016, three of six alert and oriented residents stated that they had verbalized a concern that there is not enough staff here to take care of everyone and that they expressed and felt the facility needed more staff especially on the 3:00 p.m., -11:00 p.m., shift. The three residents (Resident R26, Resident R46, Resident R57) stated that this concern was expressed at monthly resident council meetings over the last six months and that the issue had not yet been resolved. Review of the monthly resident council meeting minutes from March 2016 through August 2016 revealed that there was no documentation of the verbalized concern. In addition, there was no documented evidence that the facility had acknowledged and/or made prompt efforts to resolve the concern regarding staffing. 28 Pa. Code 201.29(j) Resident rights.

Based on review of facility policy, clinical record review, review of facility investigation and staff interview, it was determined that the facility failed to adequately supervise one of one sampled resident to prevent an elopement from the secured health care center without staff's knowledge. (Resident CR2) Findings include: Review of the facility's policy entitled Elopement Guideline, last reviewed July 21, 2016, revealed that elopement occurs when a resident leaves the premises or a safe area without authorization (i.e. an order for [REDACTED]. Clinical record review revealed that Resident CR2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE], indicated that the resident had some cognitive impairment, a history of falls and that his balance was unsteady while turning around or walking. Review of the care plan identified the resident at risk for falls due to Parkinson's and an unsteady gait. Nursing documentation on June 25, 2016, at 1:02 a.m., indicated that the resident was confused and stated, I can't find my wife or sleep right now and that he was out of bed and wandering in his room. On June 26, 2016, at 6:15 a.m. a nurse documented that the resident did not sleep all night and he stated, I just can't sleep and was restless. Again on June 27, 2016, at 12:36 a.m. a nurse noted that the resident had periods of confusion and was hallucinating. On July 5, 2016, the care plan was updated to address behaviors from the resident which included hallucinations. On July 6, 2016, at 5:56 a.m., a nurse noted that the resident had been in and out of bed all night, restless and wandering in his room and the hall. The resident was also noted as making inappropriate, sexual comments to the nursing assistants, and demanding assistance from staff but then refusing care. On July 9, 2016, at 5:27 p.m., a nurse noted that the resident was found walking in the hallway without supervision and that he had a jerky gait. Nursing documentation on July 18, 2016, at 2:47 a.m., revealed that the resident was noted with his clothes gathered over his arms standing at the back door stating, I'm going home. On July 19, 2016, at 2:15 a.m., a nurse noted that the resident was wandering unassisted in the hall and again at 3:54 a.m., a nurse noted that the resident had exhibited exit seeking behavior and was attempting to punch the door code at an exit door without success. On July 20, 2016, at 1:57 a.m., a nurse noted that the resident had exhibited exit seeking behaviors and was wandering the hall, his gait was unsteady at times, he was observed punching codes at the exit doors and he was becoming agitated with staff . Review of a facility investigation report revealed that on July 20, 2016, at 2:40 a.m., a convenience store employee called the nursing center and informed them that one of the residents was at the store.(Resident CR2) A nursing assistant picked up the resident and returned him to the center at 3:00 a.m. The resident was last seen by the 11-7 staff standing in the back hallway at the break room entrance. The resident had exited the locked nursing home and walked to a nearby store that is located at the bottom of the hill. In an interview on August 18, 2016, at 1:45 p.m., the Administrator confirmed that the resident had left the facility through a secured door without staff knowledge and walked to the store that is located at the bottom of the hill from the facility. The facility failed to reassess Resident CR2 after the resident began to display wandering behaviors and the facility failed to provide the necessary level of supervision to prevent Resident CR2 from exiting the secured nursing unit without the knowledge of staff on the 11-7 shift. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs for two of 15 sampled residents. (Resident R9, R16) Findings include: Clinical record review revealed that R9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) dated [DATE], indicated that R9 was incontintent of urine and stool and had a history of [REDACTED]. In an interview on September 27, 2013, at 9:30 a.m., the Director of Nursing confirmed that a care plan was not developed to address the incontinence and the risk for falls. Clinical record review revealed that Resident R16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident received antibiotics and was placed on Contact Precautions. The care plan, dated September 18, 2013, failed to identify that the resident had an infection and failed to include specific interventions to treat the infection and prevent the transmission of the infection. In an interview on September 27, 2013, at 9:45 a.m., the Director of Nursing confirmed that a care plan was not developed to address the infection. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observation of the medication room, it was determined that the facility failed to ensure that all drugs with the potential for abuse (controlled substances) were secured in a locked, permanently affixed compartment at all times on the nursing unit. Findings include: Observation on September 26, 2013, at 9:45 a.m., revealed fifteen vials of Ativan in the medication refrigerator, on Wing A, that were not in a separately locked and in a permanently affixed compartment. 28 PA Code 211.12(d)(1) Nursing Services