Every finding on record at Glen at Willow Valley

Based on clinical record review and staff interview it was determined the facility failed to obtain or follow physician orders for four of 40 residents reviewed. (Residents 19, 72, 134, and Resident 156) Findings include: Review of Resident 19's physician orders revealed an order dated May 8, 2023 for Tramadol Tablet (narcotic pain reliever) 50 milligrams (mg) give half a tablet by mouth two times a day for pain. Further review of Resident 19's physician orders revealed an order dated June 14, 2023 for Lorazepam (antianxiety medication) 0.5 mg tablet give one tablet by mouth two times a day for anxiety. Review of Resident 19's progress notes revealed a nurse's note dated October 21, 2023, which stated: Noted during am count of narcotics the resident received duplicate dose of [Lorazepam] 0.5mg and Tramadol 25mg between the hours of [6:00 p.m. - 8:00 p.m.] Review of Resident 19's Controlled Drug Receipts revealed Licensed Nurse Employee E3 signed out the resident's Tramadol and Lorazepam on October 20, 2023, at 6:00 p.m. Review of Resident 19's October Medication Administration Record (MAR) revealed Licensed Nurse Employee E3 did not sign the medications out as being administered on the MAR. Further review of Resident 19's Controlled Drug Receipts and October MAR revealed the next shift nurse saw that the medications were not administered per the MAR, and therefore the resident was given additional doses of the medications. Interview with the Nursing Home Administrator on November 17, 2023, at 11:25 a.m. confirmed the above findings. Review of Resident 72's physician orders revealed an order dated September 23, 2023 for Dulcolax Tablet (stool softener) Delayed Release 5 mg Give 2 tablet by mouth every 24 hours as needed for Constipation. Bowel protocol - give on day 3 as needed. Further review of Resident 72's physician orders revealed an order dated September 23, 2023 for Dulcolax Suppository 10 mg Insert 1 suppository rectally every 24 hours as needed for constipation. Bowel protocol -give on day 4 as needed. Review of Resident 72's bowel movement records revealed the resident had no bowel movement from October 20 2023 on evening shift until October 26, 2023 on day shift. A total of 6 days. Review of Resident 72's Medication Administration Record revealed Resident 72 was administered the Dulcolax tablets after 5 days of no bowel movement on November 25, 2023 at 7:46 p.m. and was documented as ineffective. Further review of the Medication Administration Record for October 2023 revealed Resident 72 was not offered the suppository. Further review of Resident 72's bowel movement record revealed the resident had no bowel movement from November 9, 2023 on day shift until November 15, 2023 on day shift, a total of 6 days. Review of Resident 72's Medication Administration Record revealed Resident 72 administered the Dulcolax tablets after 5 days with no bowel movement on November 14, 2023 at 10:01 a.m. and was documented as effective however there was no bowel movement documented on the bowel movement record on November 14, 2023. Further review of the Medication Administration record for November 2023 revealed Resident 72 was not offered the suppository. The facility failed to follow physician orders for bowel protocol by not administered bowel medication after 3 or 4 days of no bowel movement as ordered. Review of Resident 134's diagnosis list includes End Stage Renal Disease (ESRD- kidneys no longer function well enough to meet a body's needs), and Hypotension (Low blood pressure, which can cause fainting or dizziness because the brain doesn't receive enough blood). Review of Resident 134's clinical record revealed resident receives Hemodialysis (procedure where a machine and a special filter are used to clean your blood) two times a week, every Monday and Friday. Review of Resident 134's Physician's Order Sheet (POS) dated October 18, 2023, revealed an order for a daily weight before breakfast, to call the physician for a weight gain of two pounds in one day and three pounds in three days. Review of Resident 134's October 2023, Medication Administration Record (MAR) revealed no documented evidence that the resident's daily weight was taken on the following dates: October 19, 20, 21, 23, 26, 29, and 30, 2023. Review of Resident 134's November 2023, MAR revealed no documented evidence that the resident's daily weight was taken on the following dates: November 2, 5, 6, 7, and November 14, 2023. Review of Resident 134's weight and vitals record revealed a weight of 131.2 pounds on October 24, 2023, and 134.7 pounds on October 27, 2023, a 3.5-pound weight gain in three days. In addition, a weight of 133 pounds was identified on November 10, 2023, and 135.7 pounds was identified on November 11, 2023, a 2.7 weight gain in a day. Review of Resident 134's clinical record failed to reveal the physician was notified of Resident 134's identified weight gains. Interview with the Director of Nursing on November 17, 2023, at 11:00 a.m., confirmed that the physician's order regarding daily weights was not followed. Review of Resident 134's POS/progress notes dated November 8, 2023, revealed Acute visit to review BP (blood pressure), Amlodipine (a medication to treat increased blood pressure) 2.5 mg PO (by mouth) daily discontinued in hospital mid-October due to concern for low BP with fall (? Decreased fluid volume due to dialysis). The physician ordered to start Amlodipine 2.5 mg by mouth on non-dialysis days daily hold SBP (Systolic Blood Pressure) < 130 mm hg. Review of the November 2023, MAR revealed Resident 134 was administered with Amlodipine 2.5mg without checking blood pressure on the following dates: November 9, 11, 12, 14, 15, and 16, 2023. Interview with the Director of Nursing was conducted on November 17, 2023, at 11:00 a.m. The DON reported that the physician's order is faxed to the pharmacy and transcribed into the EMR (Electronic Medical Record), the nurse on duty verifies/checks the order. The DON reported that the agency nurse did not ensure that the blood pressure parameter order was transcribed into the resident's EMR and therefore Amlodipine medication was administered without first checking the resident's blood pressure thus determining if the medication needed to be held. The DON confirmed that the facility did not follow the physician's order regarding blood pressure parameters. Review of Resident 156's progress notes revealed a nursing entry dated October 8, 2023 stating Assessed resident's surgical wound and found 4cm (centimeters) X 1.5cm yellowish/macerated (the process of skin softening and breaking down as a result of prolonged exposure to foreign fluids) area at very bottom of incision site and low-grade temp of 99.9 spoke to on call PA-C (physician assistant) who advised to send resident to ER (emergency room ) for prompt treatment. Further review of Resident 156's Progress notes revealed the resident returned to the facility on [DATE]. Review of resident readmission nursing assessment dated [DATE] at 4:40 p.m. revealed mid back surgical scar with scabs .area at distal (bottom) portion measures 3.0 x 1.0 with opening draining serosanguinous (mixture of blood and clear fluid) fluid in moderate amount on 2x2 dressing (2 inch by 2 inch square of sterile gauze). Area redressed to collect and further drainage for now. Review of resident 156's physician orders revealed an order dated October 10, 2023 for Use soap and water to clean back incision then pat dry and leave OTA (open to air). Further review of resident 156's physician orders revealed there was an order dated October 14, 2023 for Santyl ointment (removed damaged tissue from wounds) apply to lower back surgical wound topically every day shift. The facility failed to provide wound care to an open wound on a surgical site from when resident 156 was readmitted to the facility on [DATE] until October 14, 2023 when the order for Santyl was completed. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of facility documentation and interview, it was determined that the facility failed to provide supervision to prevent a second fall resulting in actual harm of a identified probable nasal fracture to one of eight residents reviewed (Resident 53). This was identified as past non compliance effective September 30, 2021. Findings include: Review of facility policies and procedures failed to reveal a policy identifying when additonal supervision is warranted for outside appointments or activities. Review of Resident 53's diagnosis list revealed diagnoses including [CONDITION(S)] (irreversible, progressive [CONDITION(S)] disease of the brain resulting in loss of reality, contact and functioning ability). Review of Resident 53's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated September 13, 2021 revealed Resident 53's Brief Interview for Mental Status Score indicated severe cognitive impairment. Further review of Resident 53's Quarterly MDS revealed Resident 53 required the extensive assistance of one staff member to transfer in and out of a wheelchair. Review of Resident 53's current care plan revealed Resident 53 is at risk for falls related to a history of falls and to remind resident to request transfer assistance from staff. Review of Resident 53's Morse Fall Scale dated August 24, 2021 revealed a score of 80 indicating Resident 53 had a high probable risk for falls. Review of Resident 53's progress notes dated August 26, 2021 revealed aide alerted nurse resident had fallen. Resident was just given pain med at 1353 [1:53 p.m.] . Resident was sitting in assist dining room in w/c [wheelchair]. W/c was locked. Resident had gotten up with w/c locked and fallen near table. Resident incontinent of bladder. Resident with abrasion to L [left] side of face and lump noted to L forehead. Resident confused and impulsive. Further review of Resident 53's progress notes dated August 27, 2021 revealed went to assess resident and noted facial swelling around bilateral orbits [around eyes] with ecchymosis [bruising]. Neuro checks have been stable with VS [vital signs]. [physician] notified of my concerns for possible orbital [bones around eyes] fractures. Order received to send resident out for CT scan of head and face w/o [without] contrast. All required information faxed to CT scan office. LMSA [area emergency transportation company] notified and time will be 04:30 [4:30 p.m.] Daughter called and message left. Resident is stable at present. No c/o [complaints of] pain. Further review of Resident 53's progress notes dated August 27, 2021 revealed it was reported that on 8/27/21 at 1907 pm [7:07 p.m.] the evening supervisor received a call from [hospital] ER [emergency room ] [nurse] saying that the resident had fallen at the [hospital] outpatient pavilion after a CT scan and was transferred to the ER for an evaluation. Further review of Resident 53's progress notes dated August 28, 2021 revealed received in report at change of shift that resident was in [hospital] and would most likely be returning. At 23:30 [11:30 p.m.] on 8/27/21 spoke with [nurse at hospital]. She reported that the resident would be returning. The nurse reported that the resident had gone for a CT scan of her head and it indicated a left frontal and orbital fracture, along with a left hematoma. Prior to returning, the resident had a fall and she was brought back to [hospital] to have another CT scan done. The 2nd CT scan indicated a possible nasal fracture. This was in addition to the first CT scan. The resident arrived at 12:30 a.m. on 8/28/21. Her VSS [vital signs stable], she had no c/o pain/discomfort. Her b/l [bilateral - both sides] eyes are both bruised with the left eye closed over. She is resting comfortably at this time. Review of Employee E4's witness statement dated August 31, 2021 revealed that Employee E4 received a telephone call from Licensed RN Employee E3 and Licensed RN Employee E5 requesting information on scheduling a CT scan. Employee E4 supplied the requested information and offered to arrange transportation for Resident 53. Employee E4 subsequently arranged for transportation for Resident 53 to the hospital for the CT Scan. Interview with Employee E4 on December 2, 2021 at 9:50 a.m. revealed that Employee E4 set up transportation for Resident 53. The interview further revealed that Employee E4 did not obtain a staff person to accompany resident 53 to the hospital for the CT Scan. The interview further revealed that Employee E4 would normally ask the clinical manager if the resident needs assistance at the appointment, however Employee E4 was unfamiliar with Resident 53 because Resident 53 was not a resident on the unit where Employee E4 worked. Employee E4 was assisting Licensed Employee E5, clinical manager on Resident 53's nursing unit. Employee E4 also stated that employee was not informed that Resident 53 would need a staff person to accompany the resident to the appointment. Review of Licensed Employee E3's witness statement dated August 31, 2021 revealed that Licensed Employee E3 received a phone call from Licensed Employee E5 requesting assistance to schedule a CT Scan for Resident 53. Licensed Employee E3 called Employee E4 for assistance. Interview with Licensed RN Employee E3 on December 2, 2021 at 10:02 a.m. revealed Licensed RN Employee E3 received a telephone call from Licensed Employee E5 requesting assistance with scheduling a CT Scan. Licensed Employee E3 contacted Employee E4 to assist Licensed Employee E5. Licensed Employee E3 did not obtain a staff person to accompany Resident 53 to the hospital for the CT Scan. The interview further revealed that assigning staff persons to accompany residents to appointments is a clinical judgment by the clinical managers to determine if the resident requires someone to accompany them. Review of Licensed Employee E5's witness statement dated August 31, 2021 revealed Licensed Employee E5 asked Licensed Employee E3 how to make arrangements for a CT scan for Resident 53. Licensed Employee E3 and Licensed Employee E5 were unsure how to set up transportation and called Employee E4 for assistance. Licensed Employee E5 prepared Resident 53 for transport and obtained the appropriate paperwork. Licensed Employee E5 spoke with the transportation driver regarding Resident 53's recent fall and the transportation driver would be taking resident directly into the CT scan department. Licensed Employee E5's witness statement revealed I thought he was going to stay with her since it was such a short procedure. Licensed Employee E5 no longer works at the facility, therefore an interview of Licensed Employee E5 was not able to be obtained. Review of Resident 53's CT scan of facial bones results dated August 27, 2021 at 5:08 p.m. revealed Left orbital floor fracture without entrapment. The nasal bone is intact. Review of Resident 53's CT scan of facial bones result dated August 27, 2021 at 9:01 p.m. revealed Again noted is a mildly depressed orbital floor fracture. There are probable nasal fractures. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on December 2, 2021 at approximately 11:00 a.m. The facility failed to provide supervision for a resident with history of falls, severe cognitive impairment, high probable fall risk, extensive staff assistance, and recent fall; during an outside diagnostic appointment, resulting in Resident 53 falling from the wheelchair and requiring a second CT Scan with a result of probable nasal fractures resulting in actual harm to Resident 53. Pa. Code 210.18(b)(1) Management

Based on review of clinical record, review of documentation provided by the facility, review of policy and procedure and observation, it was determined that the facility failed to provide adequate supervision to prevent accidents for one of 41 residents reviewed (Resident #68). Findings include: Review of facility policy and procedure entitled Elopement Risk Evaluation, reviewed (MONTH) (YEAR) revealed Every resident will be evaluated for elopement risk by a licensed nurse on admission, quarterly, and as otherwise warranted by using the Elopement Risk scale in the electronic health record; if the resident has been identified as at risk for elopement, they will be evaluated for use of a transmitter bracelet that activates exit doors and elevator alarms; resident and family/responsible parties will be involved in the decision-making process whenever possible. However, ensuring resident safety is ultimately the responsibility of the Inter-disciplinary Care Plan Team and the facility; use of the transmitter bracelet will be noted on the resident's plan of care, along with other individualized approaches that may include, but are not limited to: methods of redirection, special attention by activities staff, exercise programs, attendance at scheduled programs, walking with staff supervision, evaluation of physical needs, and use of other environmental approaches; the transmitter bracelet would be removed when a resident is no longer found to be 'at risk' for elopement by the evaluation process. Review of Resident #68's [DIAGNOSES REDACTED]. Review of Resident #68's Elopement Risk Evaluations dated (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) revealed a score of 9 which indicated the resident was at risk to wander. Review of Resident #68's Elopement Risk Evaluations dated (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) revealed a score of 13 through 18 which indicated the resident was a high risk to wander. Review of Resident #68's Annual Minimum Data Set (MDS - periodic assessment of resident needs) dated (MONTH) 13, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 4 which indicated severe cognitive impairment. Review of Resident #68's Quarterly MDS dated (MONTH) 21, (YEAR) revealed a BIMS score of 3 which indicated severe cognitive impairment. Review of Resident #68's clinical progress notes dated (MONTH) 2, (YEAR) revealed resident was taken to 5th floor by Rec (recreational) therapy at 0950 (9:50 a.m.). Was signed out. At 1030 (10:30 a.m.) staff noted resident was not yet back from service and asked Rec therapy . where resident was. Rec therapy went up to 5th floor and noted resident was not on the floor. Staff began to search. Resident was then found on the 3rd floor around 10:50 (a.m.)sitting with other residents. Review of Resident #68's clinical progress notes dated (MONTH) 3, (YEAR) revealed Roam alert (devices placed on a resident wrist or ankle which alarms once the resident exits a door outside of the nursing unit) applied. Review of Resident #68's clinical progress notes dated (MONTH) 5, (YEAR) revealed Family is requesting to have Roam Alert alarm removed. Review of documentation provided by the facility and submitted to the Department of Health dated (MONTH) 18, (YEAR) revealed On 10/6/17 per family request and interdisciplinary team review, roam alert bracelet was removed. Further review of this documentation revealed Resident ambulates independently with walker. Further review of this documentation revealed Resident has no decision making capabilities. Resident has orders that he may leave the facility if attended. Review of Resident #68's clinical progress notes dated (MONTH) 18, (YEAR) revealed . (staff member) was taking a resident to the large window over looking the parking lot on the 4th floor and saw (Resident #68) walking in the handicap parking spot. Review of documentation provided by the facility and submitted to the Department of Health dated (MONTH) 18, (YEAR) revealed Resident was seen, by staff through a window, on the sidewalk by the front entrance of the(NAME)with his walker. Resident was last seen exiting his bedroom at 0900 (9:00 a.m.). Further review of this documentation revealed Prior to this, resident had roam alert in place. Review of Resident #68's clinical progress notes dated (MONTH) 18, (YEAR) revealed Roam alert applied to right wrist. Interview with the Director of Nursing on (MONTH) 22, (YEAR) at approximately 11:00 a.m. revealed that prior to (MONTH) 2, (YEAR) Resident #68 had a roam alert bracelet applied to his wrist but the roam alert was removed upon family request. The roam alert was reapplied after the occurrence on (MONTH) 2, (YEAR) and upon family request, the facility removed the bracelet on (MONTH) 5, (YEAR). This interview further confirmed that on (MONTH) 18, (YEAR) was seen outside the building wandering in the parking lot and the roam alert was reapplied. The facility failed to provide adequate supervision to Resident #68 during and after an event on (MONTH) 2, (YEAR) and failed to provide adequate supervision to the resident on (MONTH) 18, (YEAR) to prevent Resident #68 from exiting the building. 28 PA Code 211.10(d) Resident Care Policies Previously cited 3/19/17 28 PA Code 211.12(c)(d)(1)(3)(5) Nursing Services Previously cited 3/19/17

Based on clinical record review and staff interview, it was determined that the facility failed to respond to pharmacy recommendations for one of five residents reviewed (Resident #90). Findings include: Review of Resident #90's [DIAGNOSES REDACTED]. Review of Resident #90's physician's orders [REDACTED]. Pharmacy Recommendation dated (MONTH) 15, (YEAR) revealed that Resident #90 was due for a gradual dose reduction for [MEDICATION NAME]. There was no documented evidence that the physcian responded to the pharmacy recommendation regarding agreeing, or disagreeing with the pharmacy recommendation for a gradual dose reduction. Interview with the Director of Nursing on (MONTH) 22, (YEAR) at approximately 11:15 a.m. confirmed that the (MONTH) (YEAR) Pharmacy Recommendation was not addressed by Resident #90's physician. 28 Pa. Code 211.5(f) Clinical Records Previously cited 3/19/17 28 Pa. Code 211.12(d)(3) Nursing Services Previously cited 3/19/17 Based on clinical record review and staff interview, it was determined that the facility failed to respond to pharmacy recommendations for one of five residents reviewed (Resident #90). Findings include: Review of Resident #90's [DIAGNOSES REDACTED]. Review of Resident #90's physician's orders [REDACTED]. Pharmacy Recommendation dated (MONTH) 15, (YEAR) revealed that Resident #90 was due for a gradual dose reduction for [MEDICATION NAME]. There was no documented evidence that the physcian responded to the pharmacy recommendation regarding agreeing, or disagreeing with the pharmacy recommendation for a gradual dose reduction. Interview with the Director of Nursing on (MONTH) 22, (YEAR) at approximately 11:15 a.m. confirmed that the (MONTH) (YEAR) Pharmacy Recommendation was not addressed by Resident #90's physician. 28 Pa. Code 211.5(f) Clinical Records Previously cited 3/19/17 28 Pa. Code 211.12(d)(3) Nursing Services Previously cited 3/19/17

Based on observation of wound care and dressing changes; review of facility nursing competency for wound and dressing care; review of clinical record and staff interview, it was determined that the facility failed to provide proper procedures to prevent the transmission or spread of infection as evidenced by one resident out of five resident wound care and dressing changes observed. (Resident F1) Findings include: Review of the facility, RN/LPN Competency: Wound Evaluation, Measurement, Dressing & Documentation form, undated, revealed a list of 35 instructions used to accurately evaluate and measure a wound, perform wound dressing change, and document according to the standard of care. Instruction #3, included for the gathering of appropriate equipment; instruction #11, using a protective covering pad if necessary; instruction #14, discarding soiled dressing into a clean plastic trash bag. If the soiled dressing meets the standards for biohazard waste disposal, place trash bag into biohazard waste receptacle; instructions #24- 25 and #27 and instructions #30-32, removing of gloves and washing hands and following the dressing of a wound the washing of hands prior to documentation in interdisciplinary progress notes. Interview with Director of Nursing, on March 17, 2017 at 3:00 p.m. confirmed that the facility utilizes a nursing competency form entitled, RN/LPN Competency: Wound Evaluation, Measurement, Dressing & Documentation, undated, to evaluate the care of wounds, dressing and documentation according to nursing standards of care. Review of Resident F1's clinical record revealed a physician order, dated January 11, 2017 for cleansing of the left heel wound then dress with Calcium Alginate with silver (an advanced effective barrier to bacteria penetration for moderate to heavy drainage from wounds), Allevyn (multilayered foam wound dressing) and Kling (gauze wrap) every day shift. Observation made of licensed nurse, Employee E3, during wound care and redressing of Resident F1's left heel pressure ulcer, on March 17, 2017, at 10:15 a.m. revealed the following: Resident F1 was observed in recliner chair with both feet hanging off the recliner foot rest. There was no placement of a barrier pad on the carpeted floor. Employee E3 removed soiled dressing from the resident's left heel wound and showed the soiled dressing to surveyor. The soiled dressing was observed with a moderate amount of serous (drainage) and was disposed into the resident's trash can. Soiled gloves were removed and placed in resident's trash can. Employee E3 then applied clean gloves without washing her hands and began to clean resident's heel wound. During the cleansing of the wound, Employee E3 used normal saline wipes to wash the wound but prior to use did not squeeze out the wipe. Consequently, surveyor observed saline dripping, along with a piece of an unknown light tan material, which fell from the resident's left heel wound onto the carpeted floor. Licensed Employee E3 disposed of the soiled saline wipes in residents' room trash can. Prior to covering the resident's left heel wound with Kling, licensed Employee E3 indicated that she was going to wash and lotion both residents' legs and feet, then finish the dressing change with Kling wrap. Licensed Employee E3 applied clean gloves and used wet washcloths and soap from the resident's bathroom to wash both residents' legs and feet and the washcloths were tossed into the resident's trash can. With the same gloves Employee E3 used towels to dry off residents' legs and feet; these towels were thrown onto the carpeted floor, next to the trash can. With the same gloves, Employee E3 applied lotion to residents' legs and feet. Finally, with the same gloves, Employee E3 covered resident's left heel and ankle with Kling and tape. Surveyor inquired of Employee E3 if she could identify the unknown tan material which fell from the resident's left heel wound, and was still observed on the carpeted floor. Employee E3 confirmed that the tan material which was still observed on the carpeted area beneath the resident's feet was a piece of Alginate. Employee E3 further confirmed for surveyor that there was no protective covering placed on the carpeted area directly beneath the resident's feet (which were hanging off the recliner footrest), (for the purpose of collecting anything that could fall onto the carpeted area during wound care and dressing change), I always do it like this and staff will come and clean the floor. After removing gloves and without washing hands, Employee E3 gathered remaining wound supplies and exited resident's room. Surveyor followed Employee E3 to the treatment cart and observed as Employee E3 unlocked the treatment cart and returned wound supplies to the treatment cart and cleaned a pair of scissors with alcohol wipe and then placed scissors into cart. Employee E3 returned to resident's room and collected from the trash can the soiled wash cloths and placed the wash cloths onto the pile of soiled towels sitting on the carpeted floor. Employee E3 used the left hand and collected from the carpeted floor the pile of soiled linen; and then with the right hand collected the trash bag. Employee E3 was followed to the soiled linen room and disposed of the linen in the soiled linen hamper and disposed of the trash bag in the soiled trash hamper. Employee E3 then was observed washing hands in the hand sink. Surveyor inquired of Employee E3 why the trash bag which contained soiled wound dressing and wipes was not placed in a red biohazard trash bag. Employee E3 confirmed that she realized during the wound dressing change that she had forgotten to collect the bio-hazard trash bag before starting wound care. Employee E3 confirmed for surveyor that she wanted to wash her hands first, and then was going to use a red bio-hazard bag for the soiled wound dressing supplies. Employee E3 pointed out to surveyor that the red bio-hazard bags were being stored on the shelf. Employee E3 further stated and confirmed for surveyor that during Resident F1's wound dressing change, the day before Employee E3 used a red bio-hazard bag for resident's soiled dressing. While in possession of the red bio-hazard trash bag, Employee E3 put on gloves and proceeded to open up Resident F1's trash bag and dug through the trash bag until all the soiled wound dressing supplies from the wound dressing change were collected into the red bio-hazard bag. Employee E3 still wearing soiled gloves exited the soiled utility room and accompanied by surveyor then went to the biohazard storage room. Employee E3 while wearing soiled gloves opened the door to the biohazard room and opened up the freezer door and placed this infectious waste into the biohazard waste management freezer for storage until pickup. Facility failed to ensure proper infection control measures for one resident during wound care. 28 Pa. Code: 211.10(a) Resident care policies 28 Pa. Code: 211.10(c)(d) Resident care policies Previously cited 2/04/2016 28 Pa. Code: 211.12(c)(d)(1)(2)(5) Nursing services Previously cited 2/04/2016

Based on review of the clinical record and staff interview, it was determined that the facility failed to obtain a speech screening and timely diet consistencies for two out of 30 residents reviewed. (Resident I1 and K1) Findings include: Review of Resident I1's [DIAGNOSES REDACTED]. Review of the health status note dated August 23, 2016 revealed that the resident had a history of [REDACTED]. A health status note dated August 28, 2016 revealed that the resident again had difficulty eating a sandwich at dinner and the resident's diet was downgraded to mechanical soft with ground meat with nectar liquids. Review of the health status note dated December 2, 2016 (dinner meal) revealed that Resident I1 was eating peas and started choking and had difficulty breathing. The nurse did two abdominal thrusts followed by back blows and resident began coughing and bought up mucous. Coughing was encouraged and the resident was able to clear her throat. The peas were mashed and the resident was able to continue to eat without further incident. A speech evaluation order was obtained on December 5, 2016 and a request was sent to speech therapy. On December 6, 2016 the speech therapist recommended a diet level of pureed and liquid level of nectar. The order was signed by the nurse practitioner on December 8, 2016. Review of December 2016 physcian's orders revealed that it was not until December 13, 2016, five days after the speech therapist's recommendation that the change of the diet was implemented and submitted to the dietary department. Resident I1 continued to have swallowing difficulty during the interval between the speech therapist's recommendation on December 6, 2016 and the signed order of December 8, 2016 and the notification to the dietary department on December 13, 2016 as follows: review of the health status notes revealed that on December 10, 2016 at the luncheon meal, Resident I1 was coughing on fruit. On December 11, 2016 the resident had difficulty eating french fries at dinner and started coughing. She was able to clear her throat with multiple coughs. On December 12, 2016 at the luncheon meal, Resident I1 was coughing while eating fruit cocktail. The nurse documented that coughing was reduced by placing thickener in the fruit cocktail. An interview with licensed staff Employee E4, on March 18, 2017 at 11:00 a.m. confirmed that there was a delay in obtaining the suggested diet consistency for the resident experiencing swallowing difficulty. Review of Resident K1's [DIAGNOSES REDACTED]. Review of health status notes on June 28, 2016 revealed that Resident K1 was coughing at dinner on rice and fish. The health status note on June 30, 2016 revealed that the resident was coughing at the meal on vegetables and pie which were regular consistency. The note further stated that feeding the resident slower did not seem to help. The health status notes dated July 7, 2016 revealed that the nurse ground chicken up with applesauce to a consistency that the resident could chew. On July 10, 2016 the notes revealed that the resident was coughing with nectar liquids and food at lunch. On July 11, 2016, the notes revealed that the resident was coughing on tomato soup at lunch. The physician was faxed on July 10, 2016 for a diet change to mechanical soft with ground meats for coughing and a speech screen. Review of the health status notes dated July 21, 2016 revealed that the resident continued to cough on food. The nurse documented that during dinner the resident coughed on spaghetti and broccoli and was having sneezing episodes. On July 22, 2016 the nurse documented that the resident continued to have coughing and sneezing episodes. During an interview on March 19, 2017 at approximately 2:30 p.m., licensed staff, Employee E4 stated that the speech screen was not completed as ordered on July 11, 2016. Review of health status notes dated February 1, 2017 revealed that staff reported to the nurse that Resident K1 had been pocketing food for the last two days while sitting at the meal with her eyes closed. She required cueing to swallow food and would not eat finger food after placing it in her hand as she done previously. The nursing staff downgraded the resident's diet on February 2, 2017 to puree consistency with nectar liquids checking the diet order change to be temporary. Speech therapy was initiated on February 10, 2017, eight days after speech therapy orders were requested on February 2, 2017. A signed order was not obtained until February 15, 2017 for the resident's pureed consistency and nectar liquids. Review of the February 2017 physician orders [REDACTED]. During an interview on March 19, 2017 at approximately 2:30 p.m., licensed staff, Employee E4 was not able to clarify the delay in obtaining and transcribing the speech therapy and diet orders. 483.25 Quality of Care Previously cited 2/4/2016 28 Pa. Code: 211.5(f) Clinical records Previously cited 2/4/2016 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 2/4/2016

Based on review of clinical records, facility documentation, staff interviews and observation, it was determined that the facility failed to implement a plan of care for one of 29 residents reviewed relating to impaired skin integrity. (Resident L2). The finding includes: Review of Resident L2 clinical record revealed the [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - periodic assessment of needs) dated June 4, 2015, identified the resident at risk for impaired skin integrity, with a BIMS (Brief interview for mental status) score of 5 which indicated severe cognitive impairment and an anxiety disorder. The resident's current plan of care identified problems of potential for impaired skin integrity related to picking/scratching of the skin, purpura and bruising. Review of the current plan of care for Resident L2 revealed an approach initiated on October 22, 2014, for the resident to wear long sleeves/Geri-sleeves (soft, stretchable fabric for protecting fragile skin by providing coverage for the hand, forearm and elbows) to protect the skin on her arms, wrist and hands from bruising and bleeding under the skin. Further review of the plan of care revealed an additional approach initiated on December 15, 2014, to keep the fingernails trimmed (per resident's preference). Review of clinical progress notes dated May 28, 2015 at 7:45 P.M., July 2, 2015 at 6:48 P.M., July 25, 2015 at 7:26 P.M., and September 1, 2015 at 10:07 P.M., revealed that Resident L2 sustained purpura areas on the resident's arms, wrists and/or hands. Review of the clinical progress notes revealed that on August 30, 2015 at 10:42 A.M., the resident sustained [REDACTED]. Review of the clinical progress notes revealed on December 22, 2015 at 5:15 A.M., the resident was observed with a skin tear on the right, anterior (front) chest measuring 2.0 centimeters by 0.5 centimeters. Further review of the clinical progress notes revealed on December 28, 2015 at 5:45 A.M, Resident L2 was observed with 3 abrasions (scratches) measuring 1.5 inches, 3.5 inches and 4.5 inches were observed under the right abdominal fold. Review of nursing notes dated February 3, 2016 at 12:19 p.m. revealed that a nursing assistant observed a 4 centimeter by 3.7 centimeter bruise on top of the resident's left hand while providing morning care. Observation on February 3, 2016 at 10:15 a.m. and on February 4, 2015 at 10:50 a.m. revealed Resident L2 ' s fingernails were long and untrimmed and the resident was not wearing long/Geri-sleeves as indicated as approached on the plan of care. A discussion was held with licensed staff, Employee E6 on February 4, 2016 at 11:45 a.m., regarding the above mentioned findings. 28 Pa. Code 211.12(c) Nursing Services Previously cited 5/8/2015 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 5/8/2015

Based on observation of a medication administration pass, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to correctly administer medications in accordance with physician orders [REDACTED]. Findings include: Review of facility policy entitled Medication Administration, dated December, 2012 revealed that prior to administration, review and confirm MEDICATION ORDERS FOR [REDACTED]. Observation of Resident B9's medication pass on February 3, 2016 at 9:20 a.m. with Licensed Nurse Employee E3, included the administration of [MEDICATION NAME] Liquid 160 milligrams (mg) in 5 milliliters (ml). Employee E3 administered 30 ml (960 mg) of [MEDICATION NAME] Liquid to Resident B9. Review of Resident B9's physician's orders [REDACTED]. Review of Resident B9's physician's orders [REDACTED].>Further observation of Resident B9's medication pass included the administration of [MEDICATION NAME] Nebulizer. This medication was administered to Resident B9 at 9:20 a.m., one hour and twenty minutes past the ordered administration time. Interview with the Director of Nursing and Licensed Nurse Employee E3 on February 3, 2016 at 10:22 a.m. confirmed that Employee E3 administered the incorrect dose of [MEDICATION NAME] to Resident B9. Interview with the Nursing Home Administrator and Licensed Nurse Employee E4 on February 4, 2016 at approximately 11:00 a.m. confirmed that Resident B9 was administered the [MEDICATION NAME] Nebulizer at 9:20 a.m. instead of at the ordered administration time of 8:00 a.m. 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 5/8/15 28 Pa. Code 211.10(c) Resident Care Policies Previously cited 5/8/15

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for three of 29 residents reviewed (Residents A10, D2 and Q1). Findings include: Review of Resident A10's [DIAGNOSES REDACTED]. sleep patterns, appetite and/or daily routine). Review of Resident A10's December 17, 2015 physician's orders revealed an order for [REDACTED]. Review of Resident A10's December 2015 Medication Administration Record [REDACTED]. Further review of Resident A10's January 2016 Medication Administration Record [REDACTED]. Review of Resident A10's clinical progress notes and medication administration notes for December 2015 and January 2016 failed to reveal that the physician was called/notified of the blood sugar levels greater than 450 mg/dl as stated in the physician's orders. Review of Resident D2's [DIAGNOSES REDACTED]. Review of Resident D2's December 2015 physician's orders revealed a physician's order for [MEDICATION NAME] Insulin Flex Pen (medication used to treat high blood sugar), inject per sliding scale three times per day; notify physician if blood sugar levels are greater than 350 mg/dl. Review of Resident D2's December 2015 Medication Administration Record [REDACTED]. Review of Resident D2's January 2016 medication administration revealed that on January 10, 2016 at 12:00 p.m. Resident D2 had a blood sugar level of 352; January 14, 2016 at 12:00 p.m. resident had a blood sugar level of 364; January 26, 2016 at 12:00 p.m. resident had a blood sugar level of 376 mg/dl; and on January 28, 2016 at 12:00 p.m. resident had a blood sugar level of 357 mg/dl. Review of Resident D2's clinical progress notes and medication administration notes of December 2015 and January 2016 failed to reveal evidence that the physician was called/notified of blood sugar levels greater than 350 mg/dl as stated in the physician's order. Interviews with the Director of Nursing on February 3, 2016 and February 4, 2016 at approximately 11:00 a.m. confirmed that there was no documented evidence of the physician being notified as ordered on the above mentioned dates. Review of Resident Q1's physician's orders dated October 30, 2015, indicated to check blood pressure every day and notify the physician if the systolic (top number in reading) blood pressure was <90 on three consecutive readings for [MEDICAL CONDITION] (low blood pressure). Review of the weights and vitals summary for December 2015 and January 2016 revealed that the blood pressure was not obtained on 22 of 31 days and 19 of 31 days, respectively. Interview with licensed staff, Employee E5, on February 3, 2016, at 11:55 a.m. confirmed that there was no documented evidence that the blood pressures were done daily as ordered by the physician. 483.25 Quality of Care Previously cited 5/8/15 28 Pa. Code: 211.5(f) Clinical records Previously cited 5/8/15 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 5/8/15

Based on observations, review of facility policy and staff interviews, it was determined that the facility failed to ensure medications were properly stored and labeled per professional standards on one of four nursing units. (Arbor View) Findings include: Review of facility policy entitled Medication Administration, dated December, 2012 revealed that the nurse shall place a date opened sticker on the medication if one is not provided by the dispensing pharmacy and enter the date opened. Review of manufacturer's guidelines for Lantus Insulin (medication used to treat high blood sugar levels) revealed that Lantus Insulin must be discarded 28 days after opening. Further review of manufacturer's guidelines for Lantus Insulin Pen revealed that the insulin pen is not to be shared with another person. Review of manufacturer's guidelines for Levemir Insulin (medication used to treat high blood sugar levels) revealed that Levemir Insulin should be discarded 42 days after opening. Further review of manufacturer's guidelines for Levemir Insulin Pens revealed that the pen is not to be shared with another person because it may result in a risk of transmission of bloodborne pathogens. Review of manufacturer's guidelines for Novolog Insulin (medication used to treat high blood sugar levels) revealed that Novolog Insulin should be discarded 28 days after opening. Observation with Licensed Nurse Employee E4 of the Arbor View West Hall Medication Cart on February 1, 2016 at 1:00 p.m. revealed a Lantus Insulin Pen and a Levemir Insulin Pen opened with no date open sticker on either of the pens. Observation with Licensed Nurse Employee E4 of the Arbor View South Hall Medication Cart on February 1, 2016 at 1:05 p.m. revealed a Novolog Pen opened with no date open sticker on the pen. Further observation of the Arbor View South Hall Medication Cart revealed that the above-mentioned Novolog Pen, one additional Novolog Pen and one Lantus Insulin Pen did not reveal any indication, i.e. resident name, located on the pens to indicate which residents are utilizing these pens. Observation with Licensed Nurse Employee E4 of the Arbor View North Hall Medication Cart on February 1, 2016 at 1:15 p.m. revealed one Novolog Insulin Pen and one Lantus Insulin Pen with no indication, i.e. resident name, located on the pens to indicate which residents are using these insulin pens. Discussion was held with licensed Employee E4 on February 4, 2016 at approximately 11:00 a.m. regarding the above-mentioned findings. 28 Pa. Code 211.9(a)(1) Pharmacy Services 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited 5/8/15

Based on review of clinical records and review of facility's policy, it was determined that the facility failed to timely inform the physician and responsible party of a bruise that occurred for one out of 29 residents reviewed. (Resident D3) Findings include: Review of facility's investigation form for injuries of unknown origin revealed that staff is directed to notify the physician and responsible party of an injury as soon as reasonable, but no later than 24 hours after the occurrence. Review of Resident D3's nursing notes for September 2, 2015 revealed that Resident D3 sustained a bruise on the right front lower leg. Review of the facility's investigation form for this bruise revealed that Resident D3's responsible party was not notified of the bruise until September 16, 2015 at 12:50 p.m. and Resident D3's physician was not notified of the bruise until September 17, 2015 at 9:00 p.m. 28 Pa. Code 211.10(d) Resident Care Policies Previously cited 5/8/15 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 5/8/15

Based on observation and staff interview, it was determined that the facility failed to provide a clean and homelike environment on one of four units observed (Arbor View). Findings include: An initial tour with Licensed Nurse, Employee E4 of the Arbor View Unit on February 2, 2016 at approximately 1:25 p.m. revealed three large plastic bags of dirty linen located on the floor of the soiled utility room. Further observation of this room also revealed a strong urine odor within the room. 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 5/8/15

Based on a review of clinical records and staff interviews, it was determined that the facility failed to develop a comprehensive plan of care to reflect the resident's current health status for one out of 29 residents reviewed (Resident D9). Findings include: Review of Resident D9's [DIAGNOSES REDACTED].(process of removing waste products and excess water from the body). Review of Resident D9's comprehensive plan of care failed to reveal the development of a care plan with interventions to address the resident's [DIAGNOSES REDACTED]. Interview with the Nursing Home Administrator and Director of Nursing on February 4, 2016 at approximately 2:00 p.m. was held regarding the above-mentioned findings. 28 Pa. Code 211.5(f) Clinical Records Previously cited 5/8/15 28 Pa. Code 211.11(a) Resident Care Plan 28 Pa. Code 211.12(c) Nursing Services Previously cited 5/8/15 28 Pa. Code 211.12(d)(3) Nursing Services Previously cited 5/8/15

Based on a review of facility policy, clinical record review and staff interview, it was determined that the facility failed to obtain neurochecks according to facility policy for four of 29 residents reviewed (Residents C3, E9, M2, N2); failed to follow physician orders [REDACTED]. Findings include: A review of facility policy for Head Trauma Protocol, revised February 2015, revealed that the clinical monitoring of residents who sustain head trauma should include neurological check results documented in the electronic health record which consist of blood pressure, pulse, respirations, and check pupils for responsiveness taken immediately, then every 15 minutes x 4, every hour x 4, every 4 hours x 4 and every shift x 24 hours. Review of resident C3's progress notes revealed that the resident had an unwitnessed fall on October 9, 2014 at 5:10 a.m. Review of the Neurological Check Flow Sheet revealed out of the 16 times the resident's pupils should have been checked it was not done eight of those times. Further review of resident C3's progress notes revealed the resident also had an unwitnessed fall on November 11, 2014 at 11:40 p.m. Review of the resident Neurological Check Flow Sheet revealed the resident did not have their pupils checked 10 out of the 16 times. Further review of the progress notes revealed resident C3 had a fall on December 11, 2014 at 6:15 p.m. which involved the resident hitting their head and the development of bruising and swelling. Review of the fall documentation revealed there was no documented evidence that there were neurological checks completed for this resident after the fall. Review of Resident E9's progress notes revealed the resident had an unwitnessed fall on March 5, 2015 at 2:40 a.m. Review of the neurological check sheet revealed the resident did not have their pupils checked as part of the neurological exam 12 out of the 14 times the resident should have had them examined. The resident was sent out to the hospital as a result of the fall so two opportunities were not counted because the resident was not in the facility. Interview on May 8, 2015 at 11:00 a.m. with licensed nurse Employee E3 confirmed that neurologic checks should be conducted after each unwitnessed fall and a fall in which the resident hits their head. Employee E3 confirmed that they were not completed during each one of these falls for residents E9 and C3. Review of Resident M2's nursing notes revealed that she had an unwitnessed fall on March 7, 2015 at 02:15 a.m. A review of neurological checks after this fall revealed that on March 7, 2015 only two checks were done in the first hour and only one of the every one hour checks was done. Further review of nursing notes revealed that the resident had another unwitnessed fall on March 24, 2015 at 03:40 a.m. A review of neurological checks after this fall revealed that only two of the every one hour checks were done, only three of the every four hour checks were done and only two of the every shift for 24 hours was done. Review of a nursing note on May 3, 2015 revealed another unwitnessed fall at 1:45 p.m. Review of neurological checks after this fall revealed that only three of the every four hours checks were done. Review of Resident N2's nursing notes revealed that the resident had an unwitnessed fall on March 9, 2015 at 07:00 a.m. A review of neurological checks after this fall revealed that the first neurological check was not done until an hour after the event, then the every 15 minute checks x 4 were not done, only two of the every one hour checks were done, only three of the every four hour checks were done and only one of the every shift checks was done. Review of Resident O7's Resident Immunization Status Assessment, signed by the physician on March 28, 2014, revealed that the resident had a [DIAGNOSES REDACTED]. Review of the Immunization section of the electronic record revealed that the resident was administered the flu vaccination on October 8, 2014. The aforementioned findings were reported to the nursing home administrator and the director of nursing on May 8, 2015 at approximately 1:30 p.m. Review of Resident G7's Ophthalmic Re-evaluation Eye consult form dated November 6, 2014 revealed that the resident has a history of diabetes (a condition that result in too much sugar in the blood) retinopathy( a progressive damage to the retina, the light sensitive lining at the back of the eye. It is a serious sight-threatening complication of diabetes) and to rule out progression. The consult revealed a treatment plan, for the resident to be referred to a local retinal specialist for treatment. Resident G7's physician responded on November 10, 2014 in agreement with the ophthalmic consult treatment plan to send the resident to a local retinal specialist for treatment. Review of Resident G7 ' s clinical record revealed no documented evidence that the resident's power of attorney was contacted or that an arrangement was made with a local retinal specialist for treatment until February 27, 2015(four months after the consult recommendation). Review of the social service note dated February 27, 2015 revealed that the facility has been in contact with the resident's case worker regarding dental care as well as eye care. Social service note on March 3, 2015 revealed that the resident's case worker/guardian were still considering whether to pursue the treatment. Interview on May 8, 2015 at approximately 11:00 a.m. with licensed nurse, Employee E5 revealed that nursing staff had discussed the resident's eye referral and that there should have been a documentation of the discussion, at that time it was made in the resident's clinical record. However, there was no documentation of what was discussed regarding the resident's retinal specialist referral or when the discussion occurred. Review of Resident K9's Ophthalmic eye consult re-evaluation form dated January 26, 2015 revealed that the resident was seen for revaluation for Blepharitis ( inflammation of the eyelids). The consult revealed a treatment plan to initiate Refresh Tears three times a day. Review of the resident's records revealed no documentation that the referral was communicated to the physician, reviewed or acted upon. Interview on May 8, 2015 at approximately 11:00 a.m. with licensed nurse, Employee E5 revealed no documentation that the recommendation was communicated or reviewed by the physician. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(c) d)(1)(5) Nursing services

Based on observation, review of facility list of medications with special expiration date requirements and staff interview, it was determined that the facility failed to provide proper labeling of opened vials and disposal of medications as per expiration dates recommendations on two of four nursing units (2nd floor, 4th Floor). Findings include: Review of the facility list of medications with special expiration date requirements, dated December 2012, revealed that Calcitonin nasal spray (used for the treatment of [REDACTED]. Observation on May 6, 2015 at approximately 1:00 p.m., of the 4th floor East Hall medication alcove, revealed a bottle of Calcitonin salmon nasal spray for Resident O8 which had been opened on March 4, 2015. Interview with licensed nurse, Employee E4 during that observation confirmed the opened date of the nasal spray. The facility failed to dispose of a medication at or prior to the expiration date. Review of facility's policy for expiration date requirements for medications dated December 2012 revealed Eye drops will expire 60 days after opening, PPD will expire 30 days after opening and Levemir pen will expire 42 days after opening. Observations conducted with licensed nurse Employee E6 on May 5, 2015 at 5:00 p.m. of the 2nd floor medication room refrigerator revealed Tuberculin 1 milliliter 10 test vial, opened on April 3, 2015. Employee E 6 indicated at the time of the observation that opened vial is only good for 30 days and should have been discarded. Observations conducted with licensed nurse Employee E7 on May 5, 2015 at 5:10 p.m. of the 2nd floor hallway medication storage area revealed, one multi-dose insulin Flex Touch pen of Levemir insulin 100 units/milliliter, 3 milliliter size opened, without being dated and one Visine Tear drops 15 milliliter size observed opened without being dated when it was first opened. Observations conducted with licensed nurse Employee E8 on May 5, 2015 at 5:15 p.m. of another 2nd floor hallway medication storage area revealed one multi-dose size Travatan Z 0.004% eye drops observed opened without being dated when it was first opened. 28 PA Code 211.9(j) Pharmacy services 28 PA Code 211.10(c) Resident care services 28 PA Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview determined the facility failed to ensure that residents were seen timely for one of 29 residents reviewed (Resident E9) Findings include: Review of resident E9s physician orders revealed the resident was readmitted from the hospital on February 27, 2015. Review of the physician orders revealed the resident ' s readmission orders [REDACTED]. The resident was seen again by the physician on March 22, 2015 and a progress note was written March 22, 2015 but the recapitulation orders for April, 2015 were not signed was no documented evidence that the resident ' s recapitulation orders were reviewed and signed until May 5, 2015 (a total of 63 days). Interview with licensed nurse Employee E3 on May 6, 2015 at 9:30 a.m. confirmed that the resident ' s orders were not reviewed by the physician at least every thirty days as they should have been as a readmission from the hospital. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.2 (a) Physician Visits

Based on clinical record review, staff interview, and facility policy and procedure review, it was determined the facility failed to accurately document sliding scale insulin administration for three of 29 residents reviewed. (Residents: A4, E9, and I1). Findings Include: Review of resident A4 ' s [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of Resident E9 [DIAGNOSES REDACTED]. Review of the MAR for March revealed the out of a total of 124 opportunities the facility failed to correctly document whether insulin was administered or not and the amount of insulin administered a total of 35 times. Interview with licensed nurse Employee E3 on May 8, 2015 at 9:30 a.m. confirmed that the documentation incorrectly showed when insulin was administered and the amount of insulin administered on the MAR. Review of Restorative program for Resident I1 revealed that the resident will complete active range of motion three times a week. Review of restorative documentation for April, 2015 for the resident revealed that restorative care was completed for seven out of potential 12 times. Interview with licensed nurse Employee E5 in the afternoon on May 7, 2015 revealed that the resident sometimes refused care and that staff usually re-approach the resident but forget to document the resident ' s refusals for treatment and care. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on observation, review of facility policy and interview with staff, it was determined that the facility failed to ensure that staff practiced safe infection control practices while handling and processing residents personal laundry to prevent contamination, on one of two of laundry units observed. This laundry room provided services for three of four nursing care units in the Glen building. Findings include: Review of the facility's policy reviewed on May 2009 for infection control, washing instructions for contaminated linen, revealed that hygienic and common sense storage and processing of clean and soiled linen are recommended. That soiled laundry is processed in a manner that avoids transfer of microorganisms to residents, personnel and the environment. The policy further indicated that soiled laundry would be handled as if it is potentially infectious and capable of transmitting infectious disease and staff should include the use of PPE (personal protective equipment) and frequent washing of hands. Soiled linen should be handled as little as possible and with minimum agitation to prevent gross microbial (a minute life form- micro- organisms) contamination of the air and of persons handling the linen. Observation with Employee E3 on January 5, 2013, at 10: 15 a.m. of the fourth floor linen holding area in the Glen building, revealed that staffs were processing resident ' s personal laundry. Employees E 4 and E5 were observed with gloves on, sorting residents ' dirty clothing from two blue large laundry bins (approximately 4 feet long by 3 feet wide and 2 feet deep) into two laundry baskets and did not have any protective covering on their (employees) clothes. There was debris in the air as the employees sorted the dirty linen. Employees E4 and E5 were observed placing washed wet clothing directly on top of three dryers waiting to be put into the dryers (the dryers had other clothing drying at the time). Also observed in the personal laundry room was a rack containing clean clothing in close vicinity while staff were sorting of dirty clothes. Employees E4 and E5 did not clean or disinfect the laundry baskets after using them to sort the dirty clothing. During the observation Employee E5 placed clean clothes from the dryer into a laundry basket that had had been contaminated with the dirty clothing. As the employees transferred and processed the dry clothes, some of the dry clothing made contact with the staff clothing which was potentially contaminated. Employees E 4 and E5 sorted and loaded the dirty clothes into the washers, removed their gloves and did not wash their hands after removing their gloves and before loading the dryers with washed clothes and handling clean clothing. During an Interview immediately following the observation Employee E4 indicated that residents ' personal laundry for three nursing units were processed on fourth floor linen holding area, of the Glen building and that they always sorted and processed laundry without any protective clothing on. The interview revealed that hands should have been washed after removing gloves and that the laundry basket should have been cleaned and disinfected before they could place clean clothes into them. Also, that the laundry room space was small for the amount of personal laundry processed in it. Interview with Employee E 7 on January 5, 2013, at 11 a.m. confirmed 28 Pa Code: 201.18(b)(1)(3)(e)(1) Management 28 Pa.Code 211.10(d) Resident care policies. Previously cited 6/8/12

Based on a review of facility policy, clinical records, and interviews with staff, it was determined that the facility failed to address a significant weight loss in a timely manner for one resident and failed to notify dietary staff of a significant weight loss for one resident of 29 residents reviewed. (Residents A8 and M1). Findings include: Review of facility policy "Weight Variances" reviewed January 2009, revealed that a verified loss or gain of five or more pounds per month shall be reported to the Nurse Supervisor or Director of Nursing and to the Nutrition Care Supervisor. The Nutrition Care Supervisor or Manager shall determine if the weight variance is significant (5% or greater in 30 days, 7.5% or greater in 90 days and/or 10% or greater in 180 days) within 24-72 hours of notification. Review of Resident A8's physician's orders [REDACTED]. Review of Resident A8's significant assessment dated [DATE], indicated that the resident had severe cognitive impairment and [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of Resident A8's vital sign sheet revealed weight of 161.0 pounds on December 20, 2012. Weight confirmed by a reweigh on January 21, 2013, was 149.0 pounds (loss of 12.0 pounds or 7.5%). Review of nurse's note and dietary communication slip dated January 23, 2012, revealed that dietary was notified of the weight loss. Review of nutrition care progress notes revealed weight loss was addressed February 1, 2013 (eight days after notification). Interview with dietary Employee E6 on February 4, 2013, at 12:30 p.m. confirmed that a significant weight loss was 5% in one month and that a communication slip should be responded to in 24-72 hours. Employee E6 confirmed that the the resident had interventions but that the communication slip was not responded to timely (dietary review of weight loss). Review of Resident M1's significant assessment dated [DATE], indicated that the resident had cognitive impairment and [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. The physician's orders [REDACTED]. Nutrition notes dated December 13, 2012 revealed that the resident was on hospice and was followed up on the resident's weights and weight loss and that the most recent weight was stable +/- five pounds. Review of Resident M1's vital sign flow sheet revealed that the resident's weight were monitored weekly and a weight of 153.6 pounds on December 31, 2012. Weight on January 24, 2013, was 143.4 pounds (loss of 10.2 pounds or 6.6 %) and weight on January 28 and 31, 2013 were 140 pounds (total loss of 13.6 pounds or 8.8%) from December 31, 2012. Review of nurse's note and dietary communication slip revealed no documented evidence that the weight loss was communicated to the dietician as indicated in the facility's policy and to help the resident maintain the highest practicable level of wellbeing. Interview with Employee E6 on February 4, 2013, at 12:15 p.m. confirmed that a significant weight loss was 5% in one month and the resident had more than 5% weight loss, should have been communicated to the dietitian and was not. 28 Pa. Code: 211.5(f) Clinical records Previously cited 3/8/12 28 Pa. Code: 211.10(d) Resident care policies Previously cited 6/8/12 28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 6/8/12

Based on clinical record review and staff and resident interview, it was determined that the facility failed to provide routine dental services for one of 29 residents reviewed (Resident K11). Findings include: Review of Resident K11's face sheet revealed that the resident was admitted to the facility on [DATE]. Review of the resident's clinical record revealed that the resident's significant other gave a consent on April 28, 2010 for dental services be provided to the resident. Review of the entire clinical record revealed no documented evidence that the resident had been seen by the dentist for annual /and or routine dental services. Interview with nursing Employee E2 on February 5, 2012 at 1:00 p.m. revealed that there was no documented evidence that the resident had been seen by the dentist since admission. The interview confirmed that there was no evidence of a dental consultation in the resident's clinical record. 28 PA Code 211.5(f) Clinical records Previously cited 3/8/12 28 PA Code 211.12(d)(1)(3)(5) Nursing services Previously cited 6/8/12 28 PA Code 211.15(a) Dental services