Every finding on record at Harmony Physical Rehabilitation

Based on review of facility policy , documentation, and review of Centers for Disease Control (CDC) guidelines for Legionella (bacteria that causes disease found in contaminated water) control, and staff interviews it was determined that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility for eleven of twelve months (February 2024 through January 2025). Finding include: Review of the facility policy Water Management Program dated 1/16/25 indicated the facility will utilize water management practices to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Core Elements of the Water Management Plan are: 1. Establish Water Management Plan team. 2. Describe Center's water system using text and flow diagram. 3. Risk assessment with control methods and corrective actions. 4. Monitoring control measures. 5. Corrective actions. 6. Verification and validation. 7. Documentation and communication. Review of Department of Health and Human services, Centers for Medicare and Medicaid services (CMS) memo, Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) dated 7/6/18, revealed, Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread Legionella and other opportunistic pathogens in water. This policy memorandum applies to Hospitals, Critical Access Hospitals (CAHs) and Long-Term Care (LTC). However, this policy memorandum is also intended to provide general awareness for all healthcare organizations. Facilities must have water management plans and documentation that, at minimum, ensure each facility: -Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Nontuberculous Mycobacteria, Burkholderia, Stenotrophomonas, and fungi) could grow and spread in the facility water system. -Develops and implements a water management program that considers the ASHRAE (American Society of Heating, Refrigerating, and Air Conditioning Engineers) industry standard and the CDC toolkit. -Specifies testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained. -Maintains compliance with other applicable Federal, State and local requirements. Review of the ASHRAE guidance Managing the Risk of Legionellosis Associated with Building Water Systems dated December 2020, indicated the most commonly used supplemental disinfection methods are treatment with chlorine, chlorine-dioxide, copper-silver ions, and monochloramine. The guidance further indicated the recommended levels of residual chlorine are 0.50-3.00 ppm (part per million). Review of the facility provided water management information failed to include specific testing protocols and acceptable ranges for control measures along with a description of the facility's water system using a flow diagram. The facility was keeping a log of water temperatures and maintaining these levels at 140-150 degrees and then mixed down to 110 degrees for resident use. Review of the Water Management Program Control Measures did not contain a log for Point of Use Disinfectant (the level of chlorine concentration in the water) indicated to measure and record hot water and cold water chlorine concentration as point of use, and to note that chlorine concentration below 0.5 ppm and above 4.0 ppm as outside the control limits. During an interview on 2/19/25, at 9:00 a.m. the Maintenance Director stated that they did not perform any water testing because they have public water and felt that they did not need to test for this reason. They were only testing water temperatures daily in random resident rooms. During an interview on 2/20/25, at approximately 10:10 a.m. the Nursing Home Administrator confirmed that a new Maintenance Director will be starting at the facility and that the overseeing Maintenance Director from a sister facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management.

Based on a review of facility policy and investigative documents, it was it was determined that the facility failed to follow physician's orders for one of five residents (Resident R131). This was identified as past non-compliance. Review of the facility policy Medication Administration dated 1/19/23, indicated for staff to compare medication source with MAR (medication administration record) to verify resident name, medication name, form, dose, route, and time. Review of the clinical record revealed Resident R131 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs dated 12/14/23, included diagnoses of CAD and hip fracture. Review of the physician's order dated 12/14/23, indicated for Resident R131 to receive two 10 mg tablets of baclofen (medication used to treat muscle spasms) every 24 hours, as needed for pain. Total dose ordered was 20 mg. Review of facility investigation documents indicated that on 12/14/23, at approximately 8:45 a.m. Resident R131 received two 20 mg tablets, for a total dose of 40 mg. On 12/16/23, the facility initiated a plan of correction that included education for all nursing staff including Registered Nurses and Licensed Practical Nurses to ensure that safe and accurate medication practices are followed as ordered. The facility provided documentation of the in-service training that was provided to the nursing staff, including Registered Nurses and Licensed Practical Nurses, at the facility on 12/16/23, and 12/17/23, which addressed safe and accurate medication practices. Education on medication practices which included verifying resident name, medication name, form, dose, route, and time. The facility reviewed like residents for non-compliance with medication practices on 12/16/23, and it was determined that this was an isolated incident. During an interview on 1/31/24, at approximately 12:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to follow physician's orders for one of five residents.

Based on review of clinical records, and staff interview, it was determined that the facility failed to implement procedures to ensure availability of prescribed medications for four of six residents (Residents R1, R2, R3, and R4). Findings include: Review of the National Institute of Health, National Institute on Aging published information reviewed on 10/1/22, defined high blood pressure as systolic pressure of 130 or higher (first/top number, or a diastolic pressure of 80 or higher (second/bottom number). Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the facility diagnosis list included anemia (too little iron in the body causing fatigue) and aftercare following joint replacement surgery. Review of a physician's orders dated 11/5/23, indicated Resident R1 was to receive Pantoprazole (medication to treat too much stomach acid and/or damaged esophagus) 40 mg one time daily and Citalopram (anti-depressant medication) 20 mg one time daily. Review of Resident R1's Medication Administration Record (MAR) for November 2023, indicated: 11/6/23 Pantoprazole: no documentation. 11/6/23 Citalopram: documented as 14 (14 is code for order clarification). Review of progress notes for Resident R1 failed to include notes on 11/6/23, related to whether the Pantoprazole was provided, and related to the need for an order clarification for the Citalopram. Review of the facility provided inventory for the Omnicell (automated medication dispensing machine) included Citalopram 10 mg tablets and Pantoprazole 40 mg tablets. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the facility diagnosis list included heart failure (a progressive heart disease that affects pumping action of the heart muscles) and high blood pressure. Review of a physician's orders dated 11/5/23, indicated Resident R2 was to receive Finasteride (medication to treat enlarged prostate) 5 mg once daily, Rosuvastatin (medication to treat high cholesterol and triglycerides) 10 mg once daily, and Carvedilol (medication to treat high blood pressure) 25 mg twice daily. Review of Resident R2's Medication Administration Record (MAR) for November 2023, indicated: 11/9/23 Finasteride, Rosuvastatin, Carvedilol: documented as 9 (9 is code for order Other/See Nurse Notes). Review of progress notes for Resident R2 dated 11/9/23 at 10:38 a.m. and 10:39 a.m., revealed that the above medications were not in cart. Review of Resident R2's blood pressure record on 11/9/23, included a reading of 183/89 mmHg (millimeters of mercury) at 9:34 a.m. and a reading of 182/79 mmHg at 6:23 p.m. Review of the facility provided inventory for the Omnicell included Carvedilol 3.125 mg tablets. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of the facility diagnosis list included diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and urinary tract infection. Review of a physician's orders dated 11/13/23, indicated Resident R3 was to receive calcium 600+D (vitamin and mineral supplement) once in the morning, Gemfibrozil (medication to treat cholesterol), a multivitamin, and Lidoderm 5% patch (medicated patch placed on the skin for pain relief) on for 12 hours, off for 12 hours. Review of Resident R3's Medication Administration Record (MAR) for November 2023, indicated: 11/14/23 calcium 600+D, gemfibrozil, multivitamin, and Lidoderm patch 5% were documented as 9. Review of progress notes for Resident R3 dated 11/14/23 at 9:07 a.m. and 9:08 a.m., revealed that the above medications were not in cart. Review of the facility provided inventory for the Omnicell (automated medication dispensing machine) included Lidoderm 5% patches. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the facility diagnosis list included lung cancer with cancer spread to the bone, cancer related pain, and cancer related anemia. Review of a physician's orders dated 11/13/23, indicated Resident R4 was to receive Cetirizine (allergy medication) 10 mg in the morning, Cholecalciferol (vitamin supplement) 25 mcg one time per day, cyanocobalamin (medication to treat types of anemia) 1000 mcg in the morning, dronabinol (medication for appetite stimulation and to prevent nausea and vomiting caused by chemotherapy) 2.5 mg in the morning, ferrous sulfate (iron supplement for anemia) 325 mg one time per day, folic acid (vitamin supplement) 1mg one time per day, and Lidoderm 5% patch Lidoderm 5% patch (medicated patch placed on the skin for pain relief) on in AM (morning), off at HS (hour of sleep). Review of Resident R4's Medication Administration Record (MAR) for November 2023, indicated: 11/14/23: Cetirizine, Cholecalciferol, cyanocobalamin, dronabinol, ferrous sulfate, folic acid, and Lidoderm 5% patch were documented as 9. Review of progress notes for Resident R4 dated 11/14/23 at 8:16 a.m., 8:17 a.m., and 9:21 a.m., revealed that the above medications were not in cart. Review of the facility provided inventory for the Omnicell included Lidoderm 5% patches. During an interview on 11/14/23, at approximately 1:30 p.m. the Director of Nursing confirmed that the facility failed to implement procedures to ensure availability of prescribed medications for four of six residents. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records, facility investigation records, and staff interview it was determined that the facility failed to provide fall interventions for two of three residents ( Resident R1 and Resident R2). Findings include: Review of facility policy Incidents and Accidents dated 1/19/23, indicated: The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. Review of Resident R1 clinical record indicated resident was admitted on [DATE]. Review of Resident R1 MDS (minimum data set - a brief periodic assessment of resident needs) dated 8/11/23, indicated diagnosis of hypertension (a condition in which the force of the blood against the artery wall is too high) and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere in one's daily activities). Review of incident report dated indicated that Resident R1 had a fall on 8/7/23, one of the assessments/recommendations on the incident report predisposing situation factors indicated improper footwear, dated 8/7/23, Resident R1 to wear non-skid footwear (which they did not have on at the time of the fall). Review of an incident report dated 8/11/23, indicated that Resident R1 had fallen and the assessment/recommendations for Resident R1 to wear non-skid footwear (which they did not have on at the time of the fall), predisposing situation factors indicated improper footwear. Review of Resident R1 clinical record failed to include other information about Resident R1 non-skid footwear. Review of Resident R2 clinical record indicated that resident was admitted on [DATE]. Review of Resident R2's MDS dated [DATE], indicated diagnosis of hypertension and history of falling ( a sudden loss of gait causing the hitting of any part of the body to the floor). Review of Resident R2 clinical record indicated resident had falls on the following days: 7/21/23 7/22/23 7/25/23 7/28/23 7/31/23 Review of the care plans dated 8/21/23, indicated Resident R2 was to wear non-skid footwear. Review of Resident R2 clinical record and review of facility documentation failed to include other information about non-skid footwear. During an interview on 10/3/23, at 5:04 p.m. the Administrator in Training (AIT) and the Director of Nursing confirmed that no further information could be found in the clinical record for Resident R1 and Resident R2 addressing the fall preventions of non-skid footwear, and that the facility failed to provide fall interventions for Resident R1 and Resident R2. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 207.2 (a) Administrator's responsibility. 28 Pa. Code 211.10 (d) Resident care policies.

Based on a review of facility policy, observations and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition and failed to prepare and serve food in a sanitary manner creating the potential for cross contamination in the kitchenette of the facility. Findings include: Review of the facility policy Dietary Infection Control last reviewed on 1/19/23, with a previous review date of 1/20/22, indicated that the dietary department follows standards of all regulatory agencies for cleanliness and proper food storage, preparation and handling. Review of the facility policy General Sanitation of Kitchen, last reviewed on 1/19/23, with a previous review date of 1/20/22, indicated the staff shall maintain the sanitation of the kitchen through a cleaning schedule. The cleaning schedule included cleaning of cabinets, refrigerators, cutting boards, counter spaces, floors, tables, chairs, food carts, food prep appliances and microwave ovens. During an observation on 3/1/23, from 11:40 a.m. through 1230 p.m., the microwave utilized by staff outside of kitchenette was very soiled with food debris, the counter space and cabinets near this microwave which contained tea bags, sugar, napkins, etc had spills and food debris, The cabinets underneath which stored extra supplies and salad dressings was soiled with food debris throughout. The main kitchenette are had a large refrigerator/ freezer which was soiled on the outside with food debris and stains, the handles were very soiled. The inside had food debris throughout the refrigerator and freezer. The countertops of the front area, the island and the microwave areas all had food debris and spills, the cabinets below had spill marks and were unclean, The floors throughout the kitchenette had various food debris, spills, sticky substances, and a mouse trap beside the cabinet and refrigerator. The sink was full of soiled dishes and a cutting board. Dietary Manager (DM) Employee E5 was attempting to prepare a salad for a resident who came up to eat with her family, he took a prepared salad from the cart that had come from the main kitchen and took a soiled knife from the sink, put it back down in the sink and went to the drawer for another knife, cut up the salad, never washed hands before donning gloves. During the trayline observation at this same time, Dietary Aide(DA) Employee E6 was serving from two hot holding surfaces. She also had a hot griddle surface which included two hamburgers and a cut up hot dog. During the observation at 12:14 p.m., DA Employee E6 opened a drawer under the griddle area opened a bread bag, pulled out a piece, closed the bag and placed he bread on a plate, never changing gloves between tasks, contaminating bread. She then placed the hot dog on the bread. She then removed her gloves, changed gloves, no handwashing. Then got bun from another bag placed it on a plate, placed hamburger. removed glove from left hand, went into refrigerator opening with non gloved hand pulled out container with lettuce and tomato, grabbed tomato with ungloved hand pulled out a plate to cut tomato on, not using cutting board an sliced tomato holding it with her ungloved, unclean hand and placed slices on plate with hamburger. During an interview on 3/1/23, at 2:20 p.m., the Dietary Manager Employee E5 confirmed that the facility failed to maintain infection control practices for food service and failed to maintain a clean kitchen. He indicated that the facility failed to have a cleaning schedule for the kitchenette. 28 Pa. Code: 211.6(b)(c)(d) Dietary services.

Based on review of clinical record, facility documents and staff interview it was determined that the facility failed to develop comprehensive care plans for one of four residents (Resident R2). Findings include: Review of the clinical record indicated that Resident R2 was admitted to the facility on [DATE], with diagnoses which included fractured left radius(arm), fractured left hip, falls,stroke, malnutrition, muscle wasting and irregular heart beat. Review of the plan of care for Resident R2 did not include any skin preventive measures to address the potential for skin breakdown for Resident R2 until after she developed open areas. Review of the clinical record indicated that on 2/14/23, Resident R2 had developed skin breakdown of her coccyx and a right buttock skin tear. Review of the facility provided plan of care for skin/wound care was not initiated until 3/2/23. During an interview on 3/3/23, at 12:26 p.m. the Director of Nursing confirmed that the facility failed to implement a plan of care for Resident R2 timely. 28 Pa. Code: 211.11(a)(b)(c)(d) Resident care plan.

Based on review of facility policy, clinical records, observations, and staff interviews, it was determined that the facility failed to provide timely treatment and services, consistent with professional standards of practice, to prevent pressure sore development, promote healing, and prevent worsening of pressure injuries for a dependent, incontinent, at risk resident as required for one of four residents reviewed (Resident R2). Findings include: Review of the facility policy Pressure Injury Prevention and Management, last reviewed on 1/19/23, with a previous review date of 1/20/22, indicated that the facility is committed to the prevention of avoidable pressure ulcers and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. The facility shall establish and utilize a systematic approach for pressure injury prevention and management including prompt assessment and treatment. Review of the clinical record indicated that Resident R2 was admitted to the facility on [DATE], with diagnoses which included fractured left radius(arm), fractured left hip, falls,stroke, malnutrition, muscle wasting and irregular heart beat. The Minimum Data Set (MDS- A periodic assessment of resident care needs) dated 2/8/23, indicated that Resident R2 required extensive assistance with bed mobility with assistance of one staff. Review of the initial admission skin assessment dated [DATE], indicated Resident R2 had no skin issues. Review of Resident R2's admission Braden assessment dated [DATE], indicated Resident R2 was at risk for skin breakdown. Review of admission orders did not include turning and repositioning or any any preventive measures for Resident R2's skin. Resident R2 was identified as incontinent due to limited mobility. Resident R2 had no showers prior to wound being identified. Review of Physician assessments completed prior to wound development did not include Resident R2 having skin issues. Review of a skin assessment done on 2/5/23, indicated no skin issues. Review of a skin assessment done on 2/11/23, indicated no skin issues. Review of the clinical record indicated that on 2/14/23, Resident R2 had developed a 1cm (centimeter) x 1cm open area of her coccyx (tailbone) and a right buttock skin tear. Barrier cream was applied and an air mattress added. Review of an incident report dated 2/14/23, indicated that the area was assessed by the wound team on 2/15/23, and no staging had occurred at that time, The note indicated coccyx wound measured 0.9 cm x 0.6 cm x 0. 1cm with light serous drainage and left buttock cluster of two areas measured 2.3 cm x 1.9 cm x 0.1 cm, with light serous drainage. A low loss mattress in place, treatment ordered, therapy notified for pressure reduction cushion for wheelchair and recliner. Dietary consulted for nutritional support. Wound physician would see on Monday, which would be 2/20/23, 5 days later. Review of a progress note dated 2/16/23, indicated the left buttock was identified as a Stage III pressure ulcer (full-thickness skin loss potentially extending to the subcutaneous tissue - fat layer) measured 1.9 cm x 2.3 cm x 1.9 cm and two other areas measured 2.3 cm x 1.9 cm x .1cm. The note also staed Areas worsened. No changes in care. Review of the clinical record indicated that Resident R2 was sent out to the hospital on 2/17/23, and admitted for pneumonia, sepsis and a urinary infection She had also been diagnosed as having MRSA in the coccyx and buttock wounds the area were now identified as Stage IV. Review of Resident R2's care plan did not include any skin care plan/interventions until 3/3/23; after the hospital return and the area worsened with infection. During an interview on 3/3/23, at 12:26 p.m. the Director of Nursing (DON) confirmed that the facility failed to provide care and services timely to prevent an avoidable pressure ulcer which then worsened. The DON stated I don't know what else we could have done. I'm trying to come out of this having learned something, The DON stated what could I have done to prevent this wound. 28 Pa. Code:211.10(a)(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on observation, clinical record review and staff interview, it was determined the facility failed to provide nutritional services by enteral feeding as ordered by the physician for one of two residents reviewed (Residents R9). Findings include: The facility policy entitled Enteral Feeding (delivery of food or medication via tube surgically inserted into stomach)dated 1/19/23, indicated that enteral feedings may be prescribed for residents who are physically unable to take food by mouth in amounts that will support adequate nutrition. Review of admission record indicated Resident R9 admitted to the facility on [DATE]. Review of Resident R9's Minimum Data Set (MDS- periodic assessment of care needs) dated 12/30/22, indicated diagnoses of anemia (the blood doesn ' t have enough health red blood cells), respiratory failure ( a serious condition that makes it difficult to breathe on your own), and diabetes (too much sugar in the blood). Review of a physician order dated 9/22/22, indicated that Resident R9 was to receive Glucerna 1.5 via enteral tube at a rate of 55 cubic centimeters (cc.) per hour for 24 hours daily. Review of Resident R9's progress notes dated 1/3/23, indicated a blood glucose check was 257(elevated level). Resident also noted to be drenched in sweat, respirations fast at that time and use of accessory muscles to breath. Resident R9 was more lethargic (sluggish) than usual. Insulin administered as per order. blood pressure-100/52, pulse 122, respiratory rate -38, temperature -98.8, oxygen saturation 93% (the amount of oxygen in blood)) on 2L (liters) of oxygen via nasal cannula. Aerosolized breathing treatment administered. It was noted that the resident received Jevity Tube Feed instead of Glucerna as ordered by the physician. Review of facility documentation dated 1/3/23, indicated the incorrect enteral feeding product was administered to Resident R9. Interview with Director of Nursing on 1/3/23, at 2:00 p.m. confirmed the facility failed to provide nutritional services by enteral feeding as ordered by the physician for one of two residents reviewed (Residents R9). 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1) Nursing services. 28 Pa. Code: 211.10(c) Resident care policies.

Based on review of facility policy, clinical records and incident reports and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect by not performing a safe bed positioning for one of one resident reviewed (Resident R120), which resulted in actual harm of an left femur fracture requiring transfer to the hospital for admission and treatment. This was identified as harm for past non-compliance for one resident (Resident R120). Findings include: A review of the facility policy, Abuse, Alleged Resident Neglect or Misappropriation of Resident Property, dated 3/01/20, indicated that the residents have a right to remain free from verbal, sexual, physical and mental abuse; from involuntary seclusion; from neglect and from misappropriation of their property as defined by the DOH. A review of the clinical record revealed that Resident R120 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the comprehensive Minimum Data Set Assessment (MDS -resident assessment and care screening) dated 5/27/20, indicated Resident R120 was an extensive assist of two persons for transfers and bed mobility. A review of the current care plan initiated 5/19/20, indicated Resident R120 required transfer and mobility assist of 2 persons. A review of a nurse progress note dated 6/11/20, indicated the resident rolled out of the bed onto the floor. The resident complained of left leg pain, leg turned inward at left mid femur, resident unable to move leg. The resident was sent to the hospital for evaluation and treatment. A review of a hospital emergency room report dated 6/11/20, indicated that Resident R120 sustained an acute left femoral shaft fracture. A review of a facility witness statement dated 6/11/20, indicated the following: Nursing Assistant (NA) Employee E1 indicated she was doing care on Resident R120, she had her roll on her left side of the bed, I walked on the other side of the bed, pulled out the dirty brief from underneath her, while doing that, she tipped over out of the edge of the bed. Employee E1 was terminated and not available for interview. A review of an investigative report of alleged neglect submitted by the facility, dated 6/11/20, indicated that facility staff provided bed mobility with one person and rolled Resident R120 away from them during care and neglected to follow proper procedure. On 6/12/20, the facility initiated a plan of correction that included education for all nursing staff including Registered Nurses (RN's), Licensed Practical Nurses (LPN's) and Nurse Aides (NA's) to ensure that safe mobility practices are followed as ordered. The facility provided documentation of the in-service training that was provided to the nursing staff, including Registered Nurses, Licensed Practical Nurses and Nurse Aides, at the facility on 6/12/20, which addressed bed mobility. Education on proper bed positioning techniques which included, When rolling a patient in bed without assistance of another person, you should always stand at the side of the bed that the patient will be rolling toward. The facility reviewed like residents for non-compliance with proper bed positioning on 6/12/20, and it was determined that this was an isolated incident. During an interview on 3/4/22, at 12:47 p.m. the Nursing Home Administrator confirmed that the facility neglected to provide proper bed positioning for Resident R120, resulting in a fall with serious injury. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1) Nursing services.

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to properly store medications and biologicals in two of two medication refrigerators (First Floor and Second floor nursing unit medication refrigerators). Findings include: A review of the facility policy Medication Storage in the Facility dated 1/20/22, indicated medications and biologicals are stored safely, securely, and properly. A review of the manufacturer package insert for [MEDICATION(S)] (solution injected to test for [CONDITION(S)]) indicated a vial of [MEDICATION(S)] that is in use for 30 days should be discarded. During an observation on 3/3/22, at 3:30 p.m. the First-Floor nursing unit medication refrigerator contained a vial of [MEDICATION(S)] (solution injected to test for [CONDITION(S)]) which was in use, opened, and undated. During an observation on 3/3/22, at 3:45 p.m. the Second-Floor nursing unit medication refrigerator contained a vial of [MEDICATION(S)] which was in use, open, and undated. During an interview on 3/3/22 at 3.45 p.m., Registered Nurse Employee E1 confirmed that the vials of [MEDICATION(S)] were currently in use and not dated when opened by staff. 28 Pa. Code: 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies, clinical records, facility documentation and staff interviews, it was determined that the faciltiy failed follow physician orders [REDACTED]. Findings include: The facility policy Medication Orders - Preparation For Medication Administration dated 3/19/19, indicated that the medications are administered as prescribed in accordance with good nursing principles and practices. Administration - Medications are adminsitered in accordance with written orders of the attending physician. The facility policy Admission, Medication Reconciliation dated 3/19/19, indicated to maintain continuity of care for patients in their transition ot the skilled nursing unit by ensuring that medication taken prior to admission are evaluated and reordered by physician if appropriate. Upon patient's admission to the skilled nursing unit, nursing will reconcile home or prior admission medications with hospital discharge medications. The Admission Record indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Acute Care Hospital discharge medication orders indicated that Resident R1 was to receive [MEDICATION NAME] (a diuretic medication to eliminate excess water in your body) 20 mg table by mouth daily for 89 doses. Review of Resident R1's (MONTH) 2019, Medication Administration Record [REDACTED]. Review of the clinical record revealed a fax to Resident R1's physcian dated 12/8/19, that indicated - Resident R1 was admitted [DATE], the order for [MEDICATION NAME] 20mg daily x 89 doses was not transcribed on to the MAR. During an interview on 1/23/20, at 5:02 p.m. the Director of Nursing confirmed that the facility staff failed to order Resident R1's [MEDICATION NAME] 20mg x 89 doses upon admission to the facility. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on a review of facility policy, resident council minutes and staff interview, it was determined that the facility failed to make certain that grievances from Resident Council were addressed for five of eight months (May, June, July, (MONTH) and (MONTH) 2019) Findings include: The facility policy Grievances, Resident dated 3/19/19, indicated that the facility will do its best to respond to the resident's issue/concern within 24 hours after a thorough investigation is conducted. The resident (or resident representative) will receive notification of the outcome. A resident ( or resdient representative) with a problem should express it as soon as possible after it occurs. During a review of Resident Council Minutes dated 5/30/19, 6/28/19, 7/29/19, 9/30/19 and 11/22/19, there were four concerns that calls bells were too long, a room needed cleaned and food orders aren't correct. Review of the Resident Council Minutes dated 5/30/19, 6/28/19, 7/29/19, 9/30/19 and 11/22/19, revealed that the resident council concerns were not addressed. During an interview on 12/12/19, at 1:00 p.m with Nursing Home Administrator Employee confirmed that there was no documentation that the resident concerns had been investigated and that the resident council concerns were not included in the facility grievance process. 28. Pa Code: 201.18(e)(4) Management. 28. Pa Code: 201.29(i) Resident rights

Based on review of policy, clinical record and staff interview it was determined that the facility failed to make certain consistent [MEDICAL TREATMENT] communication was maintained for [MEDICAL TREATMENT] treatments for one of one residents. (Resident R86). Findings include: Review of the facility policy Resident Who Require [MEDICAL TREATMENT] last reviewed 3/19/19, indicated that communication between facilities will be handled if specifically required. Review of the clinical record revealed that Resident R86 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician orders dated 12/19, indicated that Resident R86 is to start [MEDICAL TREATMENT] on 12/6/19, and will receive treatment every Monday, Wednesday and Friday. Review of the clinical record did not include a completed [MEDICAL TREATMENT] communication form for three of the three [MEDICAL TREATMENT] visits (12/6, 12/9 and 12/11). During an interview on 12/12/19, 2:02 p.m. the Director of Nursing confirmed that the facility failed to make certain consistent [MEDICAL TREATMENT] communication was maintained for Resident R86. 28 Pa. Code: §211.5(f) Clinical records. 28 Pa. Code: §211.5(g)(h) Clinical records. 28 Pa. Code: §201.14(a)(e)(1) Management. 28 Pa. Code: §201.14(b)(3) Management. 28 Pa. Code: §211.10(c) Resident care policies. 28 Pa. Code: §211.12(c)(d)(1)(3)(5) Nursing services.

Based on review of a facility document, observations and staff interviews, it was determined that the facility failed to properly store equipment to prevent the potential of cross contamination in two of two kitchens (Harmony country kitchen and the main kitchen). Findings include: The facility was granted a permanent exception on 3/9/15, that indicated that main kitchen services were provided by the Monroeville facility located on the same property. During an observation of the Harmony country kitchen on 11/13/17, at 6:35 a.m. the plate covers were stacked and stored in an inverted position which allowed for debris to fall inside them and would require the food service worker to touch the inside of the covers in order to place them over plated food. During an interview on 11/13/17, at 6:35 a.m. Nurse Aide Employee E1 and Housekeeping Employee E2 confirmed that the plate covers were incorrectly stored and that this created the potential for food contamination. During an observation of the main kitchen area on 11/13/17, at 7:20 a.m. clean plate covers were stacked on a rack and stored in an inverted position which allowed for debris to fall inside them and would require the food service worker to touch the inside of the covers in order to place them over plated food. During an interview on 11/13/17, at 7:20 a.m. Cook Employee E3 confirmed that the plate covers were incorrectly stored and that this created the potential for food contamination. During an interview on 11/13/17, at 10:00 a.m. Food Service Director Employee E4 confirmed that the facility failed to properly store equipment to prevent the potential of cross contamination in the Harmony country kitchen and the main kitchen. 28 Pa. Code: 211.6(c)(f) Dietary services.

Based on facility policy and clinical record review, observation and staff interviews, it was determined that the facility failed to maintain accurate medication administration records for one of nine residents (Resident R1). Findings include: The facility Preparation for Medication Administration policy dated 7/5/17, indicated that if a medication order seemed unrelated to the resident's current [DIAGNOSES REDACTED]. The nurse who administered the medication dose recorded the administration on the resident's Medication Administration Record [REDACTED] The face sheet indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-periodic assessment of care needs) dated 9/20/17, included the same diagnoses. A review of the current physician orders [REDACTED]. During an observation of a medication pass on 11/14/17, at 9:45 a.m. Registered Nurse (RN) Employee E5 dispensed [MEDICATION NAME] 50 milligram tablet from the package and administered it to Resident R1 via the GT and documented on the November 2017, MAR indicated [REDACTED]. A review of Resident R1's October 2017 and November 2017, MARs indicated that from 10/14/17, through 11/14/17, every nurse documented that they gave Resident R1 the [MEDICATION NAME] by mouth. During an interview on 11/14/17, at 8:55 a.m. RN Employee E5 confirmed that Resident R1 was to receive nothing by mouth, that all medications were to be given to the resident via the GT and that the nurses failed to seek clarification from the physician regarding the route of administration for the [MEDICATION NAME]. During an interview on 11/14/17, at 9:35 a.m. the Director of Nursing confirmed that the facility failed to maintain accurate MARs for Resident R1. 28 Pa. Code: 211.5(f) Clinical records. Previously cited 11/3/16.

Based on observation, facility policy and staff interviews, it was determined that the facility failed to prevent the potential for cross contamination in one of two resident refrigerators (Second floor) and in one of two soiled utility rooms (Second floor) and failed to maintain infection surveillance records to identify and track causative organisms for nine of nine months (February 2016 through October 2016). Findings Include: The facility Infection Control policy reviewed 1/18/16, indicated that the Infection Control Program was to decrease the risk of infection to residents and personnel, and that there was on-going monitoring for infections among residents and personnel and subsequent documentation of infections that occur. The facility Infection Control Surveillance policy reviewed 1/18/16, indicated that surveillance of healthcare-associated infections would include review of culture reports (laboratory reports indicating which organism caused the infection). During an observation of the Second floor resident refrigerator on 11/1/16, at 6:40 a.m. revealed in the freezer that there were seven large ice packs and 2 small ice packs used for resident treatments stored together with a popscicle, vanilla ice cream and frozen spinach. During an observation of the Second floor Soiled Utility Room on 11/1/16, at 6:50 a.m. revealed a hopper (for disposal of human waste) cleaning brush was laying in the Utility sink. During an interview on 11/1/16, at 6:55 a.m. Employee E1 confirmed that the facility failed to properly store ice packs and hopper brush, which created a potential for cross contamination. Review of the facility Line Listing of Resident Infections for the months of February 2016 through October 2016, indicated the presence of urinary tract infections each of those months. The report did not indicate culture results to identify organisms responsible for the infections. During an interview on 11/3/16, at 1:15 p.m. the Director of Nursing confirmed that the facility failed to maintain infection surveillance records to identify and track causative organisms for the months of February 2016 through October 2016. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.10(d) Resident care policies. Previously cited 5/14/16. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. Previously cited 5/14/16.

Based on facility policy and clinical record review and staff interview, it was determined that the facility failed to complete a comprehensive Minimum Data Set (MDS) within 14 days for one of ten residents (Resident R4). Findings include: The facility Minimum Data Set and Goal Planning Schedule policy reviewed 10/3/16, indicated that there would be accurate and timely completion of MDS by all disciplines. The face sheet indicated that Resident R4 was admitted [DATE], with [DIAGNOSES REDACTED]. Review of Resident R4's clinical record on 11/2/16, did not indicate that a comprehensive MDS assessment (a core set of screening, clinical, and functional status elements, which forms the foundation of a comprehensive assessment for all residents of nursing homes) was completed as of that date. During an interview on 11/3/16, at 9:30 a.m. the Nursing Home Administrator confirmed that the facility failed complete a comprehensive MDS for Resident R4 within 14 calendar days of admission. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 211.15 (f) Clinical records.

Based on observation, facility policy and staff interview, it was determined that the facility failed to make certain that an open multidose pen had an accurate expiration date in one of two medication refrigerators. Findings include: The facility Preparation for Medication Administration policy reviewed 1/4/16, indicated that the date opened is recorded on multidose vials on the vial label or an accessory label affixed for that purpose. The facility Medication Storage in the Facility guidelines indicated that Byetta Pens are to be stored in the refrigerator and expires 28 days from date opened. During an observation on 11/1/16, at 6:40 a.m. of the Second floor medication refrigerator revealed a multidose pen of Byetta that was in an open box and did not have an open date recorded on the box or pen. During an interview on 11/1/16, at 6:45 a.m. Employee E1 confirmed that the medication had been opened and that the facility failed to make certain that an accurate expiration date was on the medication. 28 Pa. Code: 211.9(a)(1)(2)(h)(k) Pharmacy services.

Based on facility policy and clinical record review and staff interview, it was determined that the facility failed to make certain that the clinical record was complete and accurate for one of 10 residents (Resident R9). Findings include: The facility Notification of Physician and Family policy reviewed 10/3/16, indicated that nursing staff were responsible for documenting the resident's change of condition. Review of the face sheet indicated that Resident R9 was admitted [DATE], with [DIAGNOSES REDACTED]. Review of the clinical nursing note timed 10/13/16, at 10:58 p.m. indicated that Resident R9 arrived at 3:45 p.m. The note indicated that the resident sat in a chair all evening watching TV and reading, and denied pain. Review of the emergency transfer form completed 10/14/16, at 4:08 a.m. indicated that Resident R9 was transferred to the hospital to be evaluated for respiratory distress. Review of the clinical nursing notes did not include documentation of assessment of Resident R9's change in condition that warranted transfer to the hospital. During an interview on 11/3/16, at 1:15 p.m. the Director of Nursing confirmed that the facility failed to make certain that clinical nursing notes included documentation of Resident R9's change in condition and need for transfer to the hospital. 28 Pa. Code: 211.5(f)(g) Clinical records. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Based on review of facility documents and staff interview, it was determined that the facility failed to have a physician in attendance for three of three quarterly quality and compliance meetings (First, Second and Third Quarters, 2016). Findings include: Review of the signature sheets for the First, Second and Third Quarter 2016, Quality and Compliance Meetings did not indicate that a physician was in attendance. During an interview on 11/2/16, at 1:05 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that a physician was in attendance for the quarterly quality and compliance meetings in 2016. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1)(3) Management.