Every finding on record at Haven Convalescent Home, Inc

Based on a review of clinical records, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) during observation of a wound and foley catheter (tubing inserted into the bladder to drain urine) for one of 19 residents reviewed (Resident R78). Findings include: No facility policy on EBP provided. Resident R78's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (a lung disease that makes it difficult to breathe), anemia (low red blood cells in the blood which carries oxygen), hyperlipidemia (high levels of fats-cholesterol and triglycerides in the blood), and dementia (a disease affecting mood, behavior and decision making). Observation of a wound dressing change on 12/11/24, at 10:30 a.m. revealed that Registered Nurse (RN) Employee E1 and Nursing Assistant (NA) Employee E2 failed to don (put on) proper personal protective equipment (PPE) by not wearing a gown during the dressing change of Resident R78's sacral wound. During an interview with RN Employee E1 on 12/12/24, at approximately 1:00 p.m. it was confirmed that a gown should have been worn as part of EBP during the dressing change for Resident R78's sacral wound. Observation of Resident R78's room revealed that there was no signage alerting persons entering the room of EBP for infection control and no PPE available outside of the room for use. During an interview on 12/11/24, at approximately 2:20 p.m. the Director of Nursing (DON) confirmed that the facility had nine residents with foley catheters, two residents with a feeding tube, two residents with a colostomy, seven residents with a wound, and two residents with a dialysis catheter, but did not have EBP maintained for these residents. The DON further confirmed that employees should be wearing gloves and gowns when providing care for these residents. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, review of facility policies and clinical records, and staff interviews, it was determined that the facility failed to make certain that medications were secure and inaccessible to unauthorized staff and residents for two of three medication carts observed during medication pass. Findings include: The facility policy entitled Storage of Drugs and Biologicals Policy Updated 1/2020, revealed that all drug and biologicals are to be stored in locked compartments under proper temperature control. Only licensed nursing personnel are permitted access to this area and permitted to have keys for the locked drugs and biologicals. Observation of medication pass on 5/4/21, at 1:28 p.m. revealed that Licensed Practical Nurse (LPN) Employee E1 left the medication cart unattended and unsecured while administering a medication in a resident room. During an inteview with LPN Employee E2 after medication pass was completed it was confirmed the medication cart was left unlocked and out of sight while administering a medication. Observation of medication pass on 5/4/21, at 3:37 p.m. revealed that LPN Employee E2 left the medication cart unattended and unsecured while administering a medication in a resident room. During an interview with LPN Employee E2 after medication pass was completed, it was confirmed that the medication cart was left unlocked and out of sight. During an interview on 5/6/21, at 1:30 p.m. the Director of Nursing confirmed that medication carts are to be locked while the nurse administering the medication goes in to the resident room and the cart is out of sight. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to implement measures to prevent the potential for cross contamination (transfer of germs from one location to another) during a dressing change for one of two residents (Resident R5) observed for wound care. Findings include: The facility policy entitled Wound Care Procedure for Major Wounds, dated 12/02/20, indicated that staff are to wash their hands and apply clean gloves prior to wound care, following the removal of a soiled dressing and prior to cleaning the wound, and change gloves prior to applying the clean dressing. Resident R5's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R5's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation of wound care to Resident R5's left heel on 5/05/20, at 11:05 a.m. Licensed Practical Nurse (LPN) Employee E3 proceeded to disinfectant the surface of the bedside stand, open gauze packages and apply [MEDICATION(S)] solution to the opened gauze dressings. Following hand hygiene and the application of gloves, LPN Employee E3 removed Resident R5's soiled dressing, cleansed the wound with a [MEDICATION(S)] soaked gauze, fluffed another [MEDICATION(S)] soaked gauzes and applied it to the base of the wound and wrapped the area with a Kling wrap, all steps of the wound care completed wearing the original pair of gloves. During an interview, on 5/05/21, at 11:15 a.m. LPN Employee E3 confirmed that he/she performed hand hygiene and applied clean gloves prior to initiating the dressing change and did not remove gloves and perform hand hygiene at any other point during wound care. During an interview on 5/06/20, at 2:00 p.m. the facility's Infection Control Nurse confirmed that hand hygiene and glove changes should be performed between procedures that involve handling potentially contaminated (dirty) items and clean items. 28 Pa. Code 211.10(D) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, Title 49. Professional and Vocational Standards, and staff interview, it was determined that the facility failed to assure that a Registered Nurse (RN) conducted and documented a comprehensive resident wound assessment for one of five residents reviewed with wounds (Resident R5). Findings include: The Title 49. Professional and Vocational Standards, Department of State Chapter 21, State Board of Nursing, dated 1/15/05, indicated that under Responsibilities of the RN, 21.11, General Functions. (a) The registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible, and (b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered. The 21.141 Definitions, Practice of practical nursing reveals The performance of selected nursing acts in the care of the ill, injured or infirm under the direction of the licensed professional nurse, a licensed physician or a licensed dentist which do not require the specialized skill, judgement and knowledge required in professional nursing. The 21.145 Functions of the LPN [Licensed Practical Nurse], (a) . The LPN participates in the planning, implementation and evaluation of nursing care using the focused assessment in settings where nursing takes place. The facility policy entitled Wound Care Treatment Guidelines, and dated 12/02/21, revealed that weekly assessments, or more frequently as determined by the facility, should be done on all wounds requiring treatment, which should include wound measurements and a description. Resident R5's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R5's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress Notes dated 4/09/21, indicated that housekeeping staff called LPN Employee E4 into Resident R5's room due to bleeding observed on Resident R5's left sock. LPN Employee E4 documented in Progress Notes and on a Skin Observation form that area noted to left heel appears to be a blister that 'popped' the center is dark red in color with white moist edges, 3 centimeters (cm) by 2 cm in size, area of unknown cause. LPN Employee E5 documented Resident R5's next wound assessment, in Progress Notes and on a Skin Observation form both dated 4/13/21, indicating the left heel wound remained 3 cm by 2 cm, had a moderate amount of tan drainage on the old dressing with no surrounding redness or complaint of pain to the area. Progress Notes dated 4/14/21, revealed Resident R5 was transferred to a local acute care facility on 4/13/21, following a change in condition, with an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked evidence of a comprehensive wound assessment (i.e. measurements of length, width, depth; wound stage/wound bed description; drainage; pain; description of surrounding tissue) of Resident R5's heel wound, completed by an RN, at the time of discovery or prior to transfer out of the facility on 4/13/21. During an interview on 5/06/21, at 3:00 p.m. the Director of Nursing indicated that wound assessments and documentation are conducted and documented by the Registered Nurse Supervisor with referrals to the wound consultant as needed. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, observations, and staff interview, it was determined that the facility failed to assess the functional status of individual residents to determine if alternative interventions were appropriate before the use of bed rails for four of seven residents (Residents R82, R12, R37 and R65). Findings include: The Bed Rail policy, dated 9/6/19, stated that alternatives should be attempted prior to installation of bed rails such as low beds, fall mats, referral to therapies, toileting programs, etc. Resident R82's clinical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident R82's clinical note dated 10/23/19, stated that he/she requested a side rail on the left side of the bed to aid in mobility. A clinical note dated 10/30/19, stated that Resident R82 had wanted side rails on the bed to aide in bed mobility. Resident R82's current Physical Restraint care plan listed two half upper side rails on the bed. Resident R82's Minimum Data Set (MDS-periodic assessment of resident care needs) dated 10/29/19, revealed that his/her bed mobility was extensive assistance (staff provide weight-bearing support) and two plus persons physical assist. Resident R82's physical restraint elimination assessment dated [DATE], revealed a score of 14 indicating that he/she was a priority candidate for side rails to be eliminated. There was no evidence that any alternative interventions were attempted prior to placing side rails on Resident R82's bed. Resident R12's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R12's clinical note dated 7/5/17, stated that he/she requested side rails to aid in mobility. Resident R12's current Physical Restraint care plan listed two half upper side rails on the bed. Resident R12's MDS dated [DATE], revealed that his/her bed mobility was extensive assistance and two plus persons physical assist. Resident R12's physical restraint elimination assessment dated [DATE], revealed a score of 25 indicating that he/she was a good candidate for side rails to be eliminated. There was no evidence that any alternative interventions were attempted prior to placing side rails on Resident R12's bed. Resident R37's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R37's clinical note dated 3/9/18, stated that he/she requested side rails to aid in mobility. Resident R37's current Physical Restraint care plan listed two half upper side rails on the bed. Resident R37's MDS dated [DATE], revealed that his/her bed mobility was extensive assistance and two plus persons physical assist. Resident R37's physical restraint elimination assessment dated [DATE], revealed a score of 25 indicating that he/she was a good candidate for side rails to be eliminated. There was no evidence that alternative interventions were attempted prior to placing side rails on Resident R37's bed. Resident R65's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A nursing note, dated 7/11/19, at 10:29 a.m., revealed that the Resident R65 stated I am afraid I will fall off the bed and I would like to keep the bars. An MDS, dated [DATE], revealed that Resident R65 was an extensive assist for mobility and transfers with two plus person for physical assist. Resident R65's physical restraint elimination assessment dated [DATE], revealed a score of 19 indicating that he/she was a priority candidate for side rails to be eliminated. There was no evidence that alternative interventions were attempted prior to placing side rails on Resident R65's bed. 28 Pa. Code 211.8(f) Use of restraints 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 10/25/18

Based on observation and staff interview, it was determined that the facility failed to maintain the main freezer in the main kitchen in a safe and sanitary manner. Findings include: During an observation of the main kitchen on 10/23/18, at 10:19 a.m. the freezer had ice build up on inside freezer door, on the air curtain hanging inside the freezer door, around the door frame, along the molding seal of the inside freezer door, and had migrated to the outside of the freezer door into the cooler side of the door and wall. During an interview on 10/23/18, at 10:30 a.m. Dietary Manager Employee E3, confirmed the above observation. During an observation 10/25/18, at 11:14 a.m. ice build up was around the molding on the inside bottom of the freezer door, the air curtain on the inside of the freezer door and small ice formation was on the bottom of the blower fan cover. This was brought to the attention of the Nursing Home Administrator on 10/25/18, at 11:30 a.m 28 Pa. Code: 201.18(b)(1) Management.

Based on review of facility policy, personnel files and staff interview, it was determined that the facility failed to implement written policies and procedures for screening newly hired employees as required for two of five employees (Employee E1 and E2). Findings include: The facility policy entitled Prevention of Abuse, Neglect and Exploitation of Residents and Misappropriation of their Property dated 9/19/18, indicated that criminal background checks will be obtained on all new employees in accordance with state and federal regulations and the policies of Haven Convalescent. The facility policy entitled Prevention of Abuse, Neglect and Exploitation of Residents and Misappropriation of their Property dated 9/19/18, indicated that reference checks of past and present employees will be attempted by Haven Convalescent. Review of the personnel file indicated that Employee E1 began employment at the facility on 8/21/18, had not resided in Pennsylvania for two consecutive years prior to application for employment. The personnel file for Employee E1 did not inlude documentation that an application for a federal (FBI) background criminal history report had been completed and did not include documentation of any federal criminal history report. During an interview on 10/25/18, at 11:35 a.m. the Nursing Home Administrator confirmed the above findings. Review of the personnel file indicated that Employee E2 began employment at the facility on 7/3/18, did not include documentaion that reference checks had been attempted by the facility staff. Duing an interview on 10/25/18, at 10:45 a.m. the Director of Nursing confirmed that the personnel file for Employee E2 did not include documentation that reference checks had been attempted by the facility staff. 28 Pa. Code 201.14 (a) Responsibility of Licensee. Previously cited 11/13/17. 28 Pa. Code 201. 18(b)(1)(3) Management.

Based on observation, review of facility policies and clinical records and staff interviews, it was determined that the facility failed to make certain that medications were secure and inaccessible to unauthorized staff and residents,one of four medication carts (front hall East medication cart). Findings include: The facility policy entitled Preparation for Medication Administration dated 9/19/18, indicated that the (medication) cart must be locked if not clearly visible and under control of the personnel administering medications. During an observation on 10/24/18, at 4:55 p.m. revealed an unlocked and unattended medication cart in East nursing unit hall . During an interview on 10/24/18, at 5:10 p.m. Registered Nurse (RN) Employee E2 confirmed the front hall East medication cart was unattended and unsecured. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on facility policy, observation, and Resident Group and staff interviews, it was determined that the facility failed to store and serve eggs with safe food handling practices in the Main Kitchen. Findings include: A review of the facility policy Dietary Services last reviewed 9/26/17, indicated old stock is rotated and used first, and raw eggs are not to be served, they must be cooked. During an observation on 11/6/17, at 1:00 p.m. it was revealed that six trays of 30 eggs each were stored in the walk-in cooler. The eggs were not dated, one tray of eggs was on top of a box of unopened eggs and five trays of eggs were below the box. During an interview on 11/6/17, at 1:05 p.m the Kitchen Manager Employee E7 confirmed there were no dates on the eggs or egg trays to ensure rotation of old and new eggs. Employee E7 also confirmed that the eggs were unpasteurized. During the group interview on 11/8/17, at 1:30 p.m. Resident R104 indicated that she eats soft cooked or over easy (runny yolk) eggs for breakfast. Resident R107 indicated that she eats dippy eggs (runny yolk) for breakfast. During an observation of the kitchen tray line on 11/9/17, at 8:30 a.m. it was revealed that a breakfast was prepared to serve that contained an egg that was runny and not fully cooked. During an interview on 11/9/17, at 8:40 a.m. the Dietary Aid Employee E8 and Dietary manager Employee E7 confirmed that the egg was served runny and the facility failed to fully cook all eggs as required. 28 Pa. Code 211.6(d)(e): Dietary services.

Based on facility policy, observations and staff interviews, it was revealed that the facility failed to provide a sanitary environment to prevent possible cross contamination during a medication pass for three of 13 residents (Resident R24, R25 and R26), in one of two soiled utility rooms (East Nursing Unit Soiled utility room) and in one of 42 shared bathrooms (Bathroom [ROOM NUMBER]-122). Findings Include: A review of the facility policy Medication Administration: Oral dated 9/26/17, indicated that hand washing should be done prior to documentation. During an observation of a medication pass on 11/6/17, at 4:33 p.m. through 5:05 p.m. Licensed Practical Nurse(LPN) Employee E2 administered eye drops to Resident R24, removed gloves, placed eye drops on top of medication cart, charted in the Medication Administration Record (MAR), unlocked the medication cart with keys from a pocket and replaced eye drops in drawer with out performing hand washing. LPN Employee E2 medicated Resident R26, failed to perform hand washing and returned to the medication cart, prepared Resident R25's medications, administered medications to Resident R25 and then returned to the MAR to document. During an interview on 11/6/17, at 5:10 p.m. LPN Employee E2 confirmed that he/she failed to perform handwashing between resident contacts, while changing tasks and upon removal of gloves. During an observation on 11/6/17, at 12:55 p.m. of the East Nursing Unit Soiled Utility Room it was revealed that five waste receptacles were in front of the sink and in front of the hopper (receptacle used for rinsing soiled material) blocking use. During an interview on 11/6/17, at 12:58 p.m. Registered Nurse Employee E5 confirmed that the facility failed to provide a sanitary environment to prevent the potential for cross contamination by limiting access to the sink and the hopper. During an observation on 11/6/17, at 1:30 p.m. of the West wing treament cart revealed six of eight tubes of skin protectant paste, one of two moisturizing cream tubes, and three of three antifugal cream tubes (used to treat fungal skin infections) opened and not dated or labeled with resident name and comingled in the treatment cart. During an interview on 11/6/17, at 1:45 p.m. Registered Nurse Supervisor Employee E9 confirmed that the facility failed to date and label with resident name open tubes of skin protectant paste, moisturizing cream and antifungal cream and did not store the tubes separately creating the potential for cross contamination of disease. During an observation on 11/7/17, at 10:15 a.m. of shared bathroom [ROOM NUMBER]-122, it was revealed that a tube of skin barrier cream, used as a protective barrier to the buttock, was found opened and with no resident name, on the toilet. During an interview on 11/7/17, at 10:20 a.m. LPN Employee E6 confirmed the facility failed to put an identifying name on the tube of skin barrier and left it in a common bathroom with the potential for cross contamination of disease. 28 Pa. Code: 201.14(a) Responsibility of Licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 201.20(c) Staff Development. 28 Pa. Code: 211.10 (d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing Services.

Based on employee file review and staff interview it was determined that the facility failed to ensure that newly hired physical therapy employees received facility emergency preparedness training including facility evacuation procedures, fire emergency and disaster plan (Employee E10, E11, E12 and E13). Findings include: During a review of employee files on 11/13/17, at 9:20 a.m. the Employee Files of Physical Therapy staff hired in the past four months did not include documentation that the staff were trained in the emergency preparedness policies or plans of the facility. During an interview on 11/13/17, at 1:30 p.m. the Director of Physical Therapy Department Employee E1 confirmed that newly hired employees are not provided a formal training on the facilities Emergency Preparedness and Disaster Plans. 28 Pa. Code 201.14 (a) Responsibility of Licensee. 28 Pa. Code 201. 18(b)(1)(3)(d) Management. 28 Pa. Code 209.7 (a) Disaster Preparedness.

Based on observations and staff interviews, it was determined that the facility failed to provide a clean, comfortable, homelike environment in two of two central baths (East and West Wing central baths) and in seven of seven resident bathrooms on the West Wing (bathrooms 106, 110, Suite A, Suite B, 115, 116 and 120). Findings include: During an observation on 10/17/16, at 8:25 a.m. of the East Wing central bath, it was revealed that there were ceramic tiles missing around the drain in the shower stall. During an interview on 10/17/16,m at 8:30 a.m. Registered Nurse (RN) Employee E3 confirmed the the East Wing shower stall had missing ceramic tiles. During an observation on 10/17/16, at 8:00 a.m. of the West Wing central bath, it was revealed that the heat radiator board was partially dismounted from the wall, and the white walls had dark areas of discoloration. The resident bathrooms in Suite A, Suite B and 116 were painted white, devoid of decorations, and of institutional character. During an interview on 10/17/16, at 8:30 a.m. RN Employee E2 confirmed that the West Wing central bath heat radiator was not attached to the wall and that the white walls had dark stains. During an observation on 10/20/16, at 1:45 p.m. of the West Wing central bath, it was revealed that the towel bar was partially dismounted from a wall, there were rust stains in the shower, the white walls had dark stains and a sign taped above the sink indicating to wash hands was watermarked and unhomelike. The resident bathrooms in rooms 106, 110, 115 and 120 were painted white, devoid of decorations, and of institutional character. A sign taped above the toilet in room 110 indicated not to leave personal items in the bathroom and the door frame had peeling paint. During an interview on 10/20/16, at 1:50 p.m. the facility owner confirmed that the facility failed to provide a clean, comfortable homelike appearance in the central baths and bathrooms. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on review of facility document, observation and staff interview, it was determined that the facility failed to protect and maintain dignity for one of 11 residents (Resident R2). Findings include: The facility Notice of Rights of Nursing Facility Residents, document provided to all residents upon admission to the facility, indicated that residents have the right to privacy regarding medical treatment. During a dressing change observation on 10/18/16, at 12:30 p.m. revealed that Registered Nurse (RN) Employee E4 applied a dressing to Resident R2's upper inner anterior (front) thigh and then wrote his/her initials and date on the dressing. During an interview on 10/18/16, at 12:40 p.m. RN Employee E4 confirmed that the facility failed to maintain dignity for Resident R2 during a dressing change. 28 Pa. Code: 201.29 (j) Resident rights. 28 Pa. Code: 211.10 (a) Resident care policies. 28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Based on review of facility policy, clinical records and resident and staff interviews, it was determined that the facility failed to make certain that a resident was afforded the opportunity to formulate an advance directive for one of 18 residents (Resident R8). Findings include: A review of facility policies Advanced Directives and Initiation of Cardio-Pulmonary Resuscitation (CPR-life sustaining compression of the chest or giving breaths to a person when the heart or lungs fail) last reviewed ,[DATE], indicated residents have the right to formulate advance directives and initiation of CPR/DNR (Do not resuscitate) will be reviewed upon admission, at least on an annual bases and as deemed necessary. A review of the Admission Record indicated that Resident R8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS-a comprehensive assessment of the resident and care needs) dated [DATE], indicated Resident R8 was cognitively intact. A review of the Progress note dated [DATE], [DATE], [DATE] and [DATE], indicated resident R8 was able to be interviewed and had a DNR order on the chart but failed to indicate if Resident R8 was given the opportunity to discuss the DNR order. A review of the Progress note dated [DATE], indicated Resident R8 was alert and oriented, had no behaviors since two days after admission of [DATE], and was able to discuss with the nurse a medication dose reduction, a decision making skill. A review of the Minimum Data Set (MDS-a comprehensive assessment of the resident and care needs) dated [DATE], indicated Resident R8 was cognitively intact. A review of the Advance Directive Acknowledgement dated [DATE], and signed by the family, indicated Resident R8 did not have a Living Will (A residents choice of advanced directives) or a Power of Attorney (a person authorized to make medical decisions in the event the resident was incapacitated). A review of the CPR form dated [DATE], and signed by the family indicated Resident R8 should not receive CPR in the event that the heart or lungs fail. A review of the physician order [REDACTED]. A review of the clinical record on [DATE], did not include documentation that indicated Resident R8 was afforded the opportunity to choose or formulate an advanced directive. During an interview on [DATE], Resident R8 indicated that staff from the facility had not discussed the opportunity to choose an advanced directive. During an interview on [DATE], at 10:00 a.m., the Social Service Worker (SSW) Employee E1 confirmed that the facility had failed to provide Resident R8 the opportunity to choose an advanced directive. 28 Pa. Code: 201.18(b)(2) Management. 28 Pa. Code: 211.12(d)(5)Nursing services.

Based on review of facility policy, observation and staff interview, it was determined that the facility failed to properly dispose two biological and one topical medication, and failed to store refrigerated medications at acceptable temperature on one of two nursing units (East Wing nursing unit). Findings include: The facility's Preparation of Medication Administration, Medication Storage, Expiration Dates for Common Drugs and Biologicals, and Consultant Pharmacist Provider Requirements dated ,[DATE], indicated that Lantus insulin (medication to treat diabetes) expires 28 days after opened, PPD (medication to determine the presence of [DIAGNOSES REDACTED]) expires 30 days after opened, that medication refrigerators have a thermometer to make certain that medications are stored at the recommended/acceptable temperature range of ,[DATE] degrees Fahrenheit, and that the consultant pharmacist will check the medication storage facilities and submit the findings to the Director of Nursing. During an observation on [DATE], at 8:38 a.m. of the East Wing medication room revealed the following: Lantus insulin open and dated [DATE], and in use 22 days after the recommended expiration date. PPD open and dated [DATE], and in use 6 days after the recommended expiration date. Biofreeze (a topical analgesic) with an expiration date of ,[DATE]. During an interview on [DATE], at 8:43 a.m. Registered Nurse Employee E3 confirmed that the facility failed to properly dispose of expired biologicals and topical medication. During a review of the East Wing nursing unit pharmacy audit (a review of the facility medication storage facilities) dated [DATE], revealed a medication refrigerator temperature of 32 degrees Fahrenheit and was marked as standard met/no abnormality. During an interview on [DATE], at 11:00 a.m. the Director of Nursing confirmed that the [DATE], medication refrigerator temperature of 32 degrees Fahrenheit was out of the recommended/acceptable medication refrigerator storage range. 28 Pa. Code: 211.9 (a) (1) (i) (k)Pharmacy services. 28 Pa. Code: 211.12 (d) (1) (2) (3) (5) Nursing services.

Based on observations and staff interviews, it was determined that the facility failed to provide handrails to maintain a safe and functional environment for residents on one of two nursing units (West Wing nursing unit). Findings include: During observations on 11/23/15, at 12:45 p.m., and on 11/25/15, at 12:30 p.m., on the West Wing nursing unit, the wall behind a couch that was located in the hallway contained no handrail for resident safety, approximately seven feet. During an interview on 11/25/15, at 12:30 p.m., the nursing home owner Employee E2 confirmed that the facility failed to provide handrails in the hallway to maintain a safe and functional environment for residents in the West Wing nursing unit. 28 Pa. Code: 205.9(a) Corridors. 28 Pa. Code: 207.2(a) Administrator's responsibility.

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to develop and revise plans of care to reflect current resident care needs for three of 18 residents (Resident R2, R3, R15.) Findings include: A review of the facility policy Care Plans dated September 2015, indicated that care plans will be written to meet individual needs, are resident specific and will be updated to review new orders and resident needs. A review of Resident R2's progress notes dated 8/28/15, indicated that Resident R2's foley catheter (a tube inserted directly into the bladder to drain urine) was removed on that date. A review of Resident R2's current care plans indicated a care plan for a foley catheter. During an interview on 11/25/15, at 11:00 a.m., Licensed Practical Nurse Assessment Coordinator (LNAC) Employee E1 confirmed that the facility failed to revise Resident R2's care plan after the foley catheter was discontinued. A review of Resident R3's physician order dated 11/13/15, indicated [MEDICATION NAME] (a medication used help prevent blood clots from forming) 75 mg (milligram) po (by mouth) daily. A review of Resident R3's current care plans did not indicate a care plan for the potential for bleeding (a common side effect of [MEDICATION NAME].) During an interview on 11/25/15, at 11:05 a.m., LNAC Employee E1 confirmed that the facility failed to develop a care plan for the potential for bleeding for Resident R3. A review of Resident R15's physician orders dated 9/23/15, indicated [MEDICATION NAME] (a medication used to thin the blood) 150 mg po twice daily. A review of Resident R15's current care plans did not include a care plan for the potential for bleeding (a common side effect of [MEDICATION NAME].) During an interview on 11/25/15, at 11:10 a.m., LNAC Employee E1 confirmed that the facility failed to develop a care plan for the potential for bleeding for Resident R15. 28 Pa. Code: 211.11(a)(b)(c)(d) Resident care plan.

Based on a review of facility policy , observations and staff interviews, it was determined that the facility failed to properly label and secure medications on one of two nursing units (West nursing unit). Findings include: The facility "Medication Administration" policy dated September 2014, indicated that medications are administered per state regulations and per physician orders, in accordance with manufacturer's specifications and professional standards of practice. Medications are administered at the time they are prepared, and not pre-poured. During an observation of the West nursing unit medication carts and medication refrigerator on 10/14/14, at 10:40 a.m., Vancomycin liquid (a liquid antibiotic) was opened with an expiration date of 14 days after opened and a fill date of 9/26/14, an Exelon patch (a patch for alzheimers disease/dementia) was out of it's original packaging, lying in the top drawer of medication cart, and a Symbicort inhaler (inhaling medication used for pulmonary disease) was opened, without resident label and without an expiration date. During an interview on 10/14/14, at 10:30 a.m., Licensed Practical Nurse Employee E1 confirmed that the facility failed to maintain accurate labels for the above mentioned medications. 28 Pa. Code: 211.9 (a)(1)(c)(h)(j) Pharmacy services. 28 Pa Code 211.12 (d)(1)(2) Nursing services.

Based on review of Resident Assessment Instrument Manual (RAI Manual - directions for completion of the Minimum Data Set), Minimum Data Set (MDS - periodic assessment of care needs), and clinical records, and staff interviews, it was determined that the facility failed to accurately assess 11 of 19 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10 and R11). Findings include: The RAI Manual states that Section V or the Care Area Assessment (CAA) Summary of the MDS that the triggered areas are to be checked and indicated if addressed in the Care Plan, and include the location and date of where the CAA information is found. A review of MDS Section V did not include the location and date of where the CAA information for the following residents: Resident R1 - MDS 6/11/12 - all sections Resident R2 - MDS 2/19/12 - all sections Resident R3 - MDS 7/29/12 - all sections Resident R4 - MDS 1/24/12 - all sections Resident R5 - MDS 3/27/12 -all sections Resident R6 - MDS 3/2/12 - all sections Resident R7 - MDS 10/1/12 - all sections Resident R8 - MDS 1/13/12 - all sections Resident R9 - MDS 5/16/12 - all sections Resident R10 - MDS 5/11/11 - all sections Resident R11 - MDS 9/14/12 - all sections During an interview on 10/17/12, at 10:10 a.m., Registered Nurse Assessment Coordinator Employee E1 confirmed that Section V was not completed accurately for Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10 and R11. During an interview on 10/17/12, at 11:30 a.m., the Nursing Home Administrator and the Director of Nursing confirmed that MDS Sections C and V were not completed as required for the previously indicated residents. 28 Pa. Code: 211.5 (f)(g) Clinical Records. 28 Pa. Code: 211.10 (c)(d) Resident care policies. 28 Pa. Code: 211.12 (d)(5) Nursing services.

Based on the review of facility policy and clinical records and a staff interview, it was determined that the facility failed to offer annual routine dental services for one of 19 residents (Resident R1). Findings include: The facility policy "Dental Services" dated September 2012, indicated that dental services will be available to all residents for annual routine and emergency dental services. During in interview on 10/17/12, at 12:30 p.m., Resident R1 indicated that a dental appointment had never been set up for an initial or annual evaluation. Review of the clinical record indicated that Resident R1 had been admitted to the facility on [DATE]. Review of the clinical record revealed no evidence that Resident R1 was offered or received an annual dental exam by a dentist. During an interview on 10/19/12, at 10:45 a.m., the Director of Nursing confirmed that the facility failed to offer Resident R1 an annual consultation with a licensed dentist. 28 Pa Code 211.12(c)(d)(3)(5) Nursing services. 28 Pa. Code 211.15(a) Dental services.