Every finding on record at Good Shepherd Home-Bethlehem

Based on observation, it was determined that the facility failed to dispose of trash and refuse properly.Findings include:Observation of the dumpster area on January 6, 2025, at 10:53 a.m., revealed the dumpster was full of trash bags and the top lid was broken. 28 Pa Code 201.18(b)(3) Management.

Based on resident interview and observation, it was determined that the facility failed to provide a clean and comfortable environment on the nursing unit. Findings include: During a confidential resident interview on December 17, 2024, at 12:34 p.m., it was reported that the floors in resident rooms were not cleaned thoroughly. During a group interview on December 18, 2024, at 10:05 a.m., two of four residents reported that the floors on the nursing unit are not always cleaned thoroughly. On December 17, 2024, at 12:29 p.m., there was dirt and debris on the floor of room [ROOM NUMBER]. Observations on December 18, 2024, between 9:29 a.m. and 1:26 p.m., revealed the following: There was dirt and debris on the floors of rooms 204, 217, 219, and 221. The dirt and debris remained on the floor of room [ROOM NUMBER]. There was dirt, debris, and a white substance smudged on the floor of room [ROOM NUMBER] that remained through the end of the observation period. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management.

Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to prevent resident to resident physical abuse by one resident (Resident 55) to ensure that each resident was free from abuse, for one of 15 sampled residents. (Resident 29) Findings include: Review of the facility policy entitled, Prevention of Resident Abuse, last reviewed December 2, 2024, revealed that all residents within the facility shall be free from abuse regardless of whether it comes from staff, other residents, volunteers, visitors, family or friends. Clinical record review revealed that Resident 55 had diagnoses that included diffuse traumatic brain injury, anxiety, mood disorder, and impulse disorder. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had physical behaviors. Review of Resident 55's care plan revealed a behavior management plan for acting aggressively to staff and peers with an intervention for staff to ensure the resident was at arm's length away from all other residents in the facility. Review of nurses' notes dated November 22, 2024, through December 5, 2024, revealed that Resident 55 exhibited agitation and aggressive behaviors that included throwing items, attempts to grab, scratch, kick, and hit staff, showing the middle finger, and pushing tray tables. On December 7, 2024, the nurse noted that Resident 55 scratched and hit Resident 29 in the hallway. Review of the facility witness statements, revealed that Resident 55 was agitated on December 7, 2024, prior to the incident with Resident 29, and staff left him unattended in the hallway with other residents within reach. In an interview on December 19, 2024, at 11:35 a.m., the Director of Nursing confirmed that Resident 55 was left unsupervised within arm's length of other residents when he should not have been. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to provide an environment that was free from accident hazards on the nursing unit. Findings include: On October 12, 2017, at 2:05 p.m. the medication nurse (LPN2) was observed at the nurses' station approximately 50 feet away from the medication cart, which was unlocked and unattended on the West Wing of the nursing unit. There was an oxycodone pill (a controlled medication for pain) in a souffle cup on top of the unattended cart. At 2:14 p.m. LPN2 was observed walking away from the medication cart and into a resident's room. The medication cart remained unlocked and unattended until 2:19 p.m. At 2:26 p.m. LPN2 was observed walking away from the medication cart and into a resident's room. The medication cart remained unlocked and unattended until 2:30 p.m. During both these observations the surveyor was able to open the medication cart. Three residents were observed to have access to the unattended medication cart during the above timeframes. On October 13, 2017, at 9:10 a.m. the Director of Nursing confirmed that the medication carts contained an automatic lock that was set to lock after five minutes if the cart was not manually locked by the nurse and that LPN2 should have manually locked the medication cart when it was unattended. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 9/22/16

Based on clinical record review and observation of the medication pass conducted with three of four nurses, it was determined that the facility had a medication error rate of 6.25 percent from 32 medication pass opportunities. (Resident R2, R48) Findings include: Observation of the medication pass on October 11, 2017, at 9:50 a.m. revealed that LPN1 adminstered [MEDICATION NAME] 17 grams (medication to relieve constipation) in three ounces of juice to Resident R2. The pharmacy label and current physician's orders [REDACTED]. Observations on October 12, 2017, at 8:36 a.m. revealed that RN1 adminstered [MEDICATION NAME] 17 grams in four ounces of a nutritional supplement to Resident R48. The pharmacy label and current physician's orders [REDACTED]. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on clinical record review and staff interview it was determined that the facility failed to maintain essential patient care equipment in safe operating condition for eight of eight sampled residents with implanted medication devices. (Residents R2, R12, R39, R43, R45, R48, R49, R50) Findings include: Clinical record review revealed that residents with implanted medication devices would have those devices checked every Monday for functionality and medication volume. On August 22, 2016, Residents R2, R12, R39, R43, R45, R48, R49, R50, and on the following Monday, August 29, 2016, Residents R2, R12, R39, R43, did not have implanted medical device function or medication volumes checked because of a malfunction with the transmission checking device. There was no documentation to support that the malfunctioning checking device had been reported or that a work order was initiated for the device's repair. In an interview on September 22, 2016, at 11:55 a.m., the Director of Nursing stated that the weekly medication device checks had not been performed and that the device malfunction had not been reported or repaired.

Based on clinical record review, policy review and staff interview, it was determined that the facility failed to assess body weight changes for one of four sampled residents with unplanned significant weight variances. (Resident R14) Findings include: The facility policy entitled GSB Resident Weights and Weight Changes last reviewed on September 12, 2016, revealed that nursing staff was to notify the dietitian via a risk referral form of any resident's significant weight change. This included a weight loss/gain of ten pounds for a resident weighing 200 pounds or greater. The dietitian was to reassess the nutritional needs and intake of the resident with a significant weight change as defined by five percent in one month and document recommendations in the medical record and physician's call book, as necessary. Clinical record review revealed that Resident R14 had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE], identified that the resident needed total staff assistance for activities of daily living including to eat. The resident's weight record showed that the resident's monthly weight on August 12, 2016, was 104.8 kilograms (231 pounds). The next recorded weight was 78.9 kilograms (173.9 pounds) on September 4, 2016, representing a greater that ten pound (24.7 percent) weight loss in one month. The resident's weight on September 5, 2016, was 80.2 kilograms (176.8 pounds) and on September 7, 2016, 80.7 kilograms (177.9 pounds). As of September 20, 2016, there was no documented evidence to support that nursing staff notified the dietitian of Resident R14's significant weight loss via the risk referral form. There was also no documented evidence to support that the dietitian assessed the resident's documented weight loss as required by facility policy. In an interview on September 21, 2016, at 1:00 p.m., the dietitian was unable to provide documented evidence that she was notified by nursing of Resident R14's weight loss via the risk referral form and an assessment of the weight loss. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on clinical record review, staff interview, and review of documentation submitted to the Department by the facility, it was determined that the facility failed to ensure that the staff provided residents with sufficient safety and supervision to prevent falls for three of 5 residents who were dependent on staff for assistance with transfers (Residents R56, R14 and R46). Findings include: Clinical record review revealed that Resident 56 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment (MDS - a periodic assessment of resident needs) dated June 23, 2016, reflected that the resident was completely dependent on two staff for transfers and bed mobility. The resident's, Activities of Daily Living flowsheet reflected that the resident required two staff for transfers, and that the staff were to perform the transfers using a mechanical lift ( a mechanical device used to lift a resident) and a full body sling (a sling shaped device used to hold the resident). Review of the information dated July 29, 2016, submitted by the facility revealed that the resident had fallen from the lift during a transfer. The following day the facility reported that the fall occurred when a nurse aide had transferred the resident alone, and had used a three-quarter body sling, rather than the full body sling. The clinical record review revealed that initially, the only injuries noted as a result of the fall, were a laceration (a cut in the skin) and hematoma (a swollen collection of blood in the tissues) on the left side of the resident's head. However, five days later on August 3, 2016, the nurses' notes reflected that the resident's right knee was swollen, discolored, and painful to the touch. An X-ray revealed a fractured right tibia (a bone in the lower leg). The nurses' notes on August 4, 2016, at 10:30 AM reflected that the resident's physician had told the staff that this fracture was the result of the fall from the mechanical lift on July 29, 2016. The clinical record documentation reflected that the resident suffered significant pain as a result of this fracture. The nurses' notes on August 4, 2016, at 11:45 AM and 3:35 PM reflected that the resident was, crying and had, facial grimacing. Review of the August 2016, Medication Administration Record (MAR) revealed that the staff medicated the resident with Vicodin (a pain medication) and later with Percocet (a pain medication) to help relieve the pain. On August 5, 2016, at 8:30 AM the physician noted that the resident was still having pain even with the Percocet and the physician prescribed Morphine (a pain medication). Review of the MAR on August 8, 2016, revealed that the resident continued to require multiple doses of Morphine each day to manage her pain related to the tibia fracture. While reviewing this incident and additional clinical record review and staff interview, it was revealed that two other residents sustained falls when the staff failed to transfer them correctly. Clinical record review revealed that Resident R14's [DIAGNOSES REDACTED]. The nurses' notes on April 9, 2016, at 7:30 PM indicated that the resident had, slid to the floor from the wheelchair during a transfer by the staff. The Minimum Data Set assessment prior to this fall was a quarterly review assessment dated [DATE]. The assessment reflected that the resident was completely dependent on staff for transfers and bed mobility, and that the resident required the assistance of two staff for these activities. In an interview on August 8, 2016, at 11:30 AM Employee 1, the Director of Rehabilitation Services, reported that the staff had been transferring the resident to the wheelchair using a mechanical lift. Employee 1 said that the staff had failed to position the mechanical lift sling correctly under the resident, which resulted in the resident falling during the transfer. Clinical record review revealed that Resident R46 had [DIAGNOSES REDACTED]. The nurses' notes dated May 13, 2016, at 5:55 AM reflected that the resident had slid off the bed and onto the floor during a transfer by the staff. The Minimum Data Set assessment prior to this fall was a quarterly review assessment dated [DATE]. The assessment reflected that the resident required the extensive assistance of two staff for transfers and bed mobility. Employee 1 reported that the resident had fallen when a nurse aide was preparing to transfer the resident from the bed to the chair. The nurse aide sat the resident on the side of the bed and then turned away from the resident to reach for the mechanical lift. The resident fell off the bed and onto the floor. Employee 1 confirmed that not only had the nurse aide failed to supervise the resident sufficiently, but that the nurse aide had attempted the transfer alone, and not with two staff as required. 28 Pa. Code 211.10(d)(1) Resident Care Policies Previously cited 9/5/14 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited 9/5/14

Based on observation, staff interview and policy review, it was determined that the facility failed to monitor the dish machine to ensure adequate sanitizing of dishware and utensils. Findings include: Review of the facility policy Ware Washing dated July 2015, revealed that staff was to take and document dishmachine water temperatures at each meal to ensure that safe wash and sanitizing temperatures were maintained. Dietary staff was to report discrepancies in temperatures immediately to a supervisor for corrective action. The facility utilizes a high temperature dishwasher that utilizes hot water sanitization at a minimum of 180 degrees Fahrenheit at the final rinse. On October 14, 2015, at 9:25 a.m., two dietary employees (Employee 1, Employee 2) were observed operating the dishmachine. The employees reported that they had been operating the dish machine since 7:30 a.m., and had not taken or recorded water temperatures of the dishmachine that morning. A review of dish machine temperatures logs revealed that staff had failed to record dish machine temperatures that morning and at 20 additional meals since September 1, 2015. In addition, staff recorded insufficient final rinse water temperatures (less than 180 degrees Fahrenheit) on ten occasions since September 1, 2015. There was no evidence to support that dietary staff reported the insufficient water temperatures to sanitize dishware to the supervisor for corrective action. 28 Pa. Code 211.10(d) Resident care policies.

Based on observation of the dining experience , it was determined that the facility failed to promote resident dignity and provide a quality dining experience in one of one dining rooms. (Residents R5, R27, R37, R47, R60) Finding include: Observation of breakfast in the dining room on September 4, 2014, at 8:26 a.m., through 8:45 a.m., revealed that NA3 stood while feeding Residents R5 and R37 their entire meal. Observation of breakfast in the dining room on September 4, 2014, at 8:35 a.m., through 8:55 a.m., revealed that NA1 stood while feeding Resident R60 the entire meal. Observations of lunch in the dining room on September 4, 2014, at 12:20 p.m., through 12:40 p.m., revealed that NA2 stood while feeding Residents R27 and R47 their entire meal. 483.15(a) Dignity and Respect of Individuality. Previously cited 10/3/13. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/3/13.

Based on clinical record review, it was determined that the facility failed to implement a physician's order from a psychiatric consultation for one of 15 sampled residents. (Resident R31) Findings include: Clinical record review revealed that Resident R31 had [DIAGNOSES REDACTED]. The resident was seen on August 6, 2014, by a psychiatric consultant. At the time of the consult, the resident received [MEDICATION NAME] (a mood stablizing medication) 500 milligrams (mg) twice a day and 250 mg at bedtime. The consulting physician recommended that the resident's [MEDICATION NAME] dose be decreased to 250 milligrams twice a day. The resident's attending physician signed and documented "okay" on the consultation report. There was no evidence to support that staff implemented the physician's order. 483.25 Quality of Care. Previously cited 10/3/13 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 10/3/13

Based on observation, it was determined that the facility failed to ensure that the resident's environment was free from accident hazards on one of one nursing unit. Findings include: Observations on September 4, 2014, revealed that scissors were left on top of the medication cart unattended from 8:50 a.m. to 9:00 a.m., 9:15 a.m. to 9:18 a.m., and 9:40 a.m. to 9:44 a.m.. The scissors were readily accessible to one resident with a history of suicidal ideations (Resident R29) 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 10/3/13 ````

Based on clinical record review and staff interview, it was determined that the pharmacist failed to identify and report medication irregularities for two of 15 sampled residents. (Resident R28, R54) Findings include: Clinical record review revealed that Resident R28 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Current physician's orders [REDACTED]. There was no documented evidence that during the monthly reviews, the pharmacist addressed the required gradual dose reduction or risk-benefit analysis. In an interview on October 2, 2013, at 7:31 a.m., the Director of Nursing confirmed that there was no documented evidence that the pharmacist had identified this was addressed. Clinical record review revealed that Resident R54 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On May 11, 2011, a physician ordered Abilify daily (antipsychotic medication). There was no documented evidence that the pharmacist identified the need for a gradual dose reduction or risk-benefit analysis. 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 develop specific care plan interventions to address the use of [MEDICAL CONDITION] medications for six of 15 sampled residents. (Residents R17, R19, R28, R31, R43, CR1) Findings include: Clinical record review revealed that Resident R17 had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment and Care Area Assessment (CAA) dated September 25, 2013, revealed that the resident received [MEDICATION NAME] (antianxiety medication) and [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) daily. There was no evidence that the facility developed a comprehensive care plans to address the use of the antianxiety and antipsychotic medications. Clinical record review revealed that Resident R19 had [DIAGNOSES REDACTED]. There was no evidence that the facility developed a comprehensive care plan to address the use of the hypnotic medication. Clinical record review revealed that Resident R28 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of the MDS and CAA assessment dated [DATE], indicated that the resident received an antipsychotic medication ([MEDICATION NAME]) daily. There was no evidence that the facility developed a comprehensive care plan to address the use of the antipsychotic medication. Clinical record review revealed that Resident R31 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of the MDS and CAA dated September 25, 2013, revealed that the resident received [MEDICATION NAME] (used to treat mental disorders), [MEDICATION NAME]. There was no evidence that the facility developed a comprehensive care plan to address the use of the antipsychotic medication. Clinical record review revealed that Resident R43 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the MDS and CAA dated August 7, 2013, revealed that the resident received [MEDICATION NAME] (used to treat mental disorders) daily. There was no evidence that the facility developed a comprehensive care plan to address the use of the medication. Clinical record review revealed that Resident CL1 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of the MDS and CAA dated July 19, 2013, revealed that the resident received [MEDICATION NAME] (used to treat brain disorders). There was no documented evidence that the facility developed a comprehensive care plan to address the use of the medication. In an interview on October 3, 2013, at 7:31 a.m., the Director of Nursing confirmed that the aforementioned residents did not have specific care planned interventions to address the use of [MEDICAL CONDITION] medications. 28 Pa Code 211.5(f) Clinical records.

Based on clinical record review and staff interview, it was determined that the facility failed to implement physician's order in a timely manner for one of 15 sampled residents. (Resident R43) Findings include: Clinical record review revealed that Resident R43 had [DIAGNOSES REDACTED]. A Minimum Data Set assessment completed on August 7, 2013, indicated that the resident required total assistance for all care needs. On November 6, 2012, a physician ordered laboratory studies to be done in eight weeks to evaluate results of the medication [MEDICATION NAME] (a cholesterol lowering drug). Review of the clinical record revealed that the laboratory studies were not completed until May 1, 2013. In an interview on October 3, 2013, at 1:25 p.m., the Director of Nursing confirmed that the studies were not completed as ordered. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 9/7/12

Based on clinical record review and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions prior to the administration of an anti-anxiety medication for one of nine sampled residents who had physician's orders [REDACTED]. Findings include: Clinical record review revealed that Resident R33 had [DIAGNOSES REDACTED]. Review of the Medication Administration Records for June, July, August and September 2013 revealed that staff administered the as needed antianxiety medication ten times. There was no documented evidence that staff had attempted non-pharmacological interventions prior to administering the antianxiety medication. In an interview on October 3, 2013, at 11:40 a.m., the Director of Nursing confirmed that staff were to attempt and document non-pharmacological interventions prior to administering as needed antianxiety medications. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to ensure that care and services were provided in an environment that enhanced each resident's dignity while feeding three of 15 sampled residents. (Residents R28, R55, R60) Findings include: Observation on October 2, 2013, from 12:40 p.m., until 1:20 p.m., revealed CNA1 standing while feeding Resident R28, R55, and R60 in the dining room across from the nurses' station. In an interview on October 3, 2013, at 12:00 p.m., the Director of Nursing confirmed that staff were to sit while feeding residents their meals in order to promote a dignified dining experience. 28 Pa. Code 201.29(j) Resident rights.

Based on a review of facility policy, clinical record review and staff interview, it was determined that the facility failed to thoroughly investigate an allegation of abuse for one of fifteen sampled residents. (Resident R50). Findings include: Review of the facility policy entitled "Report of Suspected Abuse" (dated February 4, 2013) revealed that the facility was to immediately investigate any allegation of abuse. Clinical record review revealed that Resident R50 had a Minimum Data Set Assessment (MDS) completed on August 2, 2013 that indicated that the resident was cognitively intact. The roommate of Resident R50 reported to the Director of Nursing (DON) that CNA2 was verbally abusive to Resident R50 on about September 25, 2013. There was no evidence that the facility attempted to interview Resident R50 or that they conducted an investigation into the allegation. In an interview on October 3, 2013, at 1:50 p.m., the DON confirmed that an investigation was not conducted in accordance with facility policy. 28 Pa. Code: 201.18(e)(1) Management

Based on clinical record review, staff interviews, resident interview, and review of facility policy, it was determined that the facility failed to thoroughly investigate an incident regarding a resident who had been found driving a motorized wheelchair on a busy, four lane highway for one of two residents identified as being at risk for falls or injury. (Resident R48) Findings include: The facility is located on a large campus that includes a hospital and numerous other medical buildings. The parking lots for these buildings are interconnected. Approximately 0.4 miles due south of the facility is a shopping mall. The shopping mall and the hospital campus are separated by a two lane road called Westgate Drive. The facility and hospital campus, as well as the shopping mall, are bordered to the east by Schoenersville Road, a busy four lane highway. (From the facility, it is possible to travel to the shopping mall via the parking lots on the facility/hospital campus, then crossing Westgate Drive and entering the mall parking lot, thus avoiding Schoenersville Road.). Review of facility policy entitled "Outdoor Wheelchair Safety" (last revised 2009) revealed that it was the responsibility of the "interdisciplinary team" to provide "education" "to each resident in accordance with their cognition level." Clinical record review revealed that Resident R48 had been admitted to the facility in 2009 and had [DIAGNOSES REDACTED]. The most recent minimum data set assessment dated [DATE], reflected that the resident was unable to walk, and that he used a wheelchair for mobility. (Observations made throughout the survey revealed that the resident drove a motorized wheelchair.) Review of the current care plan dated June 13, 2012, revealed that to prevent accidental injury, the resident needed to "be involved in a fall/injury prevention program." Care plan approaches to address this need included that the resident was to be "properly" assessed for outdoor wheelchair mobility, and that the resident was to receive education regarding safety during..."off campus wheelchair mobility"... The care plan reflected that these approaches were to be implemented by physical therapy staff. Nurses' notes dated July 15, 2012, at 4:45 PM reflected that the resident was seen driving his wheelchair along Schoenersville Road (the four lane highway mentioned above), and crossing over part of this highway to access the road that leads to the facility parking lot. A review of the physical therapy progress notes for the period of June 7, 2012 through July 13, 2012, reflected that Resident R48 was independent with wheelchair mobility on the facility's campus "and/or familiar areas." In an interview on September 6, 2012, at 11:25 a.m., the Physical Therapist (Employee1) said that he was aware of the incident regarding Resident R48. He said that the resident had been returning from a nearby shopping mall. He said that it was not safe for the resident to have been driving a wheelchair on the four lane highway. He said the term "familiar areas," documented in the aforementioned physical therapy progress notes, referred to the facility's sister facility in a nearby city, and did not refer to the shopping mall. Employee1 said that, at the time of this incident, the resident had not been assessed to determine if he was able to safely go to and from the mall. Employee1 said that if a resident desired to go to the mall, staff provided education to the resident on how to travel there via the interconnected parking lots on the facility and hospital campus, crossing Westgate Drive, and entering the mall parking lot. Employee1 said that this education would include staff accompanying the resident at least once, to ensure that the resident knew the way and could travel there safely. Employee1 said that after the incident on July 15, 2012, staff advised Resident R48 not to travel alone again to the mall until staff could provide this education. In an interview on September 7, 2012, at 9:00 AM, Resident R48 said that he had never traveled to the mall before July 15, 2012. He said on that day, he had needed to buy something, and so had told the nurse he was going, via his wheelchair, to the mall. He said the nurse advised him to travel through the facility and hospital parking lots, and cross Westgate Drive, to get to the mall. The resident said when he was returning from the mall, he decided to travel on Schoenersville Road. In an interview on September 5, 2012 at 1:50 PM, the Director of Nursing said that staff did not document an incident report regarding this. There was a lack of evidence that the facility had investigated where the resident had travelled that day, how long the resident had been on Schoenersville Road without staff's knowledge, or why the resident had taken this route. There was a lack of evidence that the facility had assessed the resident to determine his level of safety awareness. There was a lack of evidence that the facility addressed that physical therapy staff had not educated the resident on how to travel safely to and from the shopping mall, prior to his leaving the facility alone on July 15, 2012. 28 PA Code 211.10(d) Resident care policies

Based on observation and staff interview, it was determined that the facility failed to ensure that resident equipment was handled in a safe and sanitary manner for one of two residents who utilized respiratory equipment. (Resident R41) Findings include: Observations on September 5, 2012. at 10:18 a.m., 12:54 p.m., and again on September 6, 2012, at 7:37 a.m., and 10:00 a.m., revealed that Resident R41's oxygen tubing was draped over the top and behind the oxygen concentrator and was unbagged. In an interview on September 6, 2012, at 11:18 a.m., the Director of Nursing stated that all respiratory equipment was to be in a plastic bag when the equipment was not in use. 28 Pa. Code 211.12(d)(5) Nursing services.