Every finding on record at Highlands At Wyomissing

Based on observation, facility policy review, and staff and resident interview, it was determined that the facility failed to ensure that hot beverages were monitored and served at a safe temperature on the nursing units which placed residents at risk for burn injuries. ([NAME] Court, units 100, 200, and 300) This failure resulted in an Immediate Jeopardy situation. Findings include: Review of documentation by the American Burn Association's Burn Prevention Committee entitled, Scald Injury Prevention, revealed that a scald injury occurred when a hot liquid damaged one or more layers of skin and hot beverages were a frequent source of scald burns. Older adults were the most frequent victims of scald injuries due to thin skin, reduced mobility, and reduced ability to feel heat. Hot liquid at a temperature of 155 degrees Farenheit (F) could result in a scald injury in one second. Review of the facility policy entitled, Service Temperatures, last reviewed July 2024, revealed that staff were to ensure that temperatures were within critical limits and that coffee was to be a minimum of 150 degrees F and a maximum 180 degrees F. The policy indicated that hot beverages could be served at temperatures greater than 155 degrees F, contrary to the safety parameters outlined by the American Burn Prevention Committee. Observation during a test tray audit conducted on May 20, 2025, at 11:53 a.m., at the time the last resident meal tray was served, it was determined that the coffee provided on the tray was 179 degrees F. In an interview during the tray audit, Dietary Manager (DM) 1 confirmed the temperature of the coffee was 179 degrees F and that temperature was excessively hot for coffee at the point of service. In an interview on May 20, 2025, at 12:04 p.m., Dietary Aide (DA) 1 stated that she did not test the temperature of the coffee before the start of service or before the trays left the kitchen. She also stated that she did not typically test the temperature of the coffee before service to residents. There was a lack of evidence to support that any staff were testing the temperature of the coffee before service to residents. In an interview on May 20, 2025, at 1:20 p.m., DM 1 stated that Residents 1, 3, 4, 8, 14, and 23 typically ordered and drank coffee from the dietary department on a regular basis. In an interview on May 20, 2025, at 1:30 p.m., the Administrator stated that the facility did not have a procedure in place to assess a resident's ability to safely manage hot beverages. In interviews on May 20, 2025, at 4:10 p.m., and 4:22 p.m., Residents 4 and 8 stated that the coffee was often served hot and they could not drink it when served. On May 20, 2025, at 3:36 p.m., the Administrator was notified that the failure to ensure hot beverages were served at a safe temperature constituted an Immediate Jeopardy situation at F 804 K, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility provided an acceptable action plan for removal of the Immediate Jeopardy on May 20, 2025, at 7:19 p.m. The facility's action plan contained the following: 1. The temperature of hot beverages would be recorded by a dietary aide on a log at the start of every meal service. If the temperature of the beverage exceeded 150 degrees F, the liquid would be poured into a serving vessel to allow time to cool to the appropriate temperature and the temperature would be retested to ensure it was within range before service. 2. Dining services revised their policy to reflect a safe serving temperature of hot beverages to be between 130 degrees F and 150 degrees F. 3. All scheduled dietary staff who were onsite were educated on the safe service temperature of hot beverages and the procedure to monitor temperatures of hot beverages. One hundred percent (%) of all staff would be educated by May 23, 2025. 4. The Dietary department would contact the manufacturer of the coffee machine on May 21, 2025, to determine if the setting of the machine could be adjusted to brew at a lower temperature. The settings would be adjusted if able to do so. 5. The Dietary Supervisor would conduct weekly audits of the temperature logs to ensure that temperatures were properly obtained and were within the safe range for service. 6. If it was determined that temperatures of hot beverages were not being obtained before meal service or that hot beverages were being served outside of the safe temperature range, an additional in-service would be held with dietary staff to ensure understanding. The survey team validated that Immediate Jeopardy was removed on May 20, 2025, at 7:19 p.m., through observation, staff interview, review of staff training, and review of the facility policy and procedure following the facility's implementation of the action plan for removal of the Immediate Jeopardy. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to electronically transmit encoded Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services (CMS) within 14 days after the facility completed the resident assessment for one of three sampled residents who were discharged from the facility. (Resident 45) Findings include: Clinical record review revealed that Resident 45's discharge MDS assessment was completed on December 20, 2024, but had not been exported as of May 20, 2025. In an interview on May 21, 2025, at 11:00 a.m., Registered Nurse 1 confirmed that the MDS assessment had not been exported.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the resident's representative(s) of transfer(s), including the reasons for the moves and Ombudsman information, in writing upon transfer from the facility for two of three sampled residents who were transferred to the hospital. (Residents 7, 16) Findings include: Clinical record review revealed that Resident 7 was transferred to the hospital on March 22, 2025, after a change in condition. There was no documentation to support that the resident and the resident's responsible party or legal representative were provided with written information regarding the transfer to the hospital. Clinical record review revealed that Resident 16 was transferred to the hospital on December 23, 2024, after a change in condition. There was no documentation to support that the resident and the resident's responsible party or legal representative were provided with written information regarding the transfer to the hospital. In an interview on May 21, 2025, at 12:20 p.m., the Administrator confirmed that there was no evidence that the residents and residents' representatives were given written notices regarding the identified transfers. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to monitor and assess nutritional status for two of 15 sampled residents. (Residents 18 and 42) Findings include: Review of the facility policy entitled Weight Policy, last reviewed February 19, 2024, revealed that the purpose of the policy was to monitor residents' weight status. When a resident's recorded weight showed a five percent difference, plus or minus, from the previous weight, a re-weight was to be obtained. The provider was to be notified of any weight loss or weight gain of five percent or greater. Weights were to be reviewed weekly by the dietician, their designee, and nursing to determine significant changes. Clinical record review revealed that Resident 18 had diagnoses that included autoimmune hemolytic anemia, congestive heart failure and chronic leukemia. A review of the care plan revealed that the resident's nutritional status was at risk of being compromised due to chronic lymphocytic leukemia. Review of the resident's weights revealed that on June 5, 2024, her weight was 104.4 pounds. On June 29, 2024, her weight was 122.5 pounds which indicated that she had a weight gain of 18.1 pounds which was greater then five percent. There was no documented evidence that the staff re-weighed the resident to verify the accuracy of the weight and the significant weight gain. In an interview on July 18, 2024, at 11:00 a.m., the Director of Nursing confirmed that the resident had not been re-weighed as per facility policy. Clinical record review revealed that Resident 42 had diagnoses that included congestive heart failure, Alzheimer's disease, and dysphagia (difficulty swallowing). Review of Resident 42's care plan revealed his nutritional status was compromised. On May 20, 2024, Resident 42 weighed 155.1 pounds and on June 5, 2024, he weighed 144.1 pounds, a significant weight loss of over seven percent. There was no documented evidence that the physician was notified of the significant change. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a group interview and staff interview, it was determined that the facility failed to ensure that each resident's call bell was answered in a timely manner for three of four alert and oriented residents. (Residents 17, 20, 58) Findings include: During a group interview on July 17, 2024, at 9:40 a.m., Residents 17, 20, and 58 reported that it takes long periods of time of (30 minutes or more) for staff to answer their call bells and get assistance. In an interview on July 18, 2024, at 11:00 a.m., the Administrator revealed that staff was expected to respond to a call light within six minutes. Review of the facility form entitled, Zone Activity Report, for Residents 17, 20, and 58, revealed from July 1 through July 17, 2024, there were 44 occurrences when the call bell response time exceeded more than six minutes including on July 5, at 5:54 p.m., when Resident 17 waited 49 minutes, July 13, at 9:53 a.m., when Resident 20 waited 41 minutes, and July 6, 2024, at 2:06 p.m., when Resident 58 waited 60 minutes. In an interview on July 18, 2024, at 11:40 a.m., the Adminstrator confirmed Residents 17, 20, and 58 waited more than the expected response time of six minutes. 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 ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's current status for three of fourteen sampled residents. (Residents 161, 26, 41) Findings include: Clinical record review revealed that Resident 161 had diagnoses that included anxiety and altered mental status. Section B of the MDS assessment dated [DATE], indicated that the resident was not in a vegetative state, had clear speech, was able to make themself understood and could understand others. Section C of the same assessment indicated that the resident's ability to participate in the brief interview for mental status (BIMS, an interview to determine cognitive status) was not assessed. Clinical record review revealed that Resident 26 had diagnoses that included dementia. Section B of the MDS assessment dated [DATE], indicated that the resident had clear speech, usually understood others, and was sometimes understood. Section C of the same assessment indicated that the resident could never understand others, was never understood, and the BIMS was not conducted. Clinical record review revealed that Resident 41 had diagnoses that included dementia without psychotic disturbance, mood disturbance, and anxiety. Section B of the MDS assessment dated [DATE], indicated that the resident was not in a vegetative state, had clear speech, usually made themself understood, sometimes understood others, and had adequate hearing. Section C of the same assessment indicated that the resident could never understand others, was never understood, and the BIMS was not conducted. In an interview on June 29, 2023, at 9:58 a.m., the Registered Nurse Assessment Coordinator (RNAC) confirmed that the brief interview for mental status should have been attempted and the MDS assessments should have been coded accordingly. CFR 483.20 Accuracy of Assessments. Previously cited 7/8/22

Based on facility policy review, personnel record review, and staff interview, it was determined that the facility failed to ensure that staff orientation included in-service training on the identification, prevention and reporting of resident abuse for five of five sampled staff. (NA 1, NA 2, LPN 1, LPN 2, RN 1) Findings include: Review of facility policy entitled, Resident Abuse Policy, dated December 30, 2021, revealed that during orientation and annually thereafter, staff were to receive in-service training on identification, prevention, and reporting of resident abuse, exploitation, and neglect, and the improper use of physical and chemical restraints. Review of personnel records revealed a lack of evidence to support that nurse aides (NA 1 and NA 2), licensed practical nurses (LPN 1 and LPN 2), and a registered nurse (RN 1) had received training on identifying, preventing and reporting of resident abuse during orientation, prior to working with residents. In an interview on July 8, 2022, at 11:50 a.m., the Director of Nursing confirmed there was no evidence the employees received abuse training during staff orientation, before staff worked with residents. In an interview on July 8, 2022, at 12:54 p.m., the Nursing Home Administrator confirmed there was no evidence that abuse training was provided to employees at staff orientation, before staff worked with residents. 28 Pa. Code 201.28(e)(1) Management. 28 Pa. Code 201.20 (c) Staff development. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, review of wound evaluation documentation, and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set assessment was completed accurately to reflect the resident's status for three of 16 sampled residents. (Resident 5, 19, 32 ) Findings include: Clinical record review revealed that Resident 5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of section M of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident 5 did not have one or more areas of unhealed pressure ulcers/injuries. Review of wound evaluation documentation dated March 30, 2022, revealed that Resident 5 had a stage three pressure ulcer to the left buttock for at least 47 days duration, which was not identified on the MDS assessment. In an interview on July 8, 2022, at 11:07 a.m., the Director of Nursing confirmed that section M on the MDS assessment for Resident 5 was coded inaccurately and should have indicated a pressure ulcer/injury was present during the review period. Clinical record review revealed that Resident 32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of section M of the MDS assessment dated [DATE], indicated that Resident 32 did not have one or more areas of unhealed pressure ulcers/injuries. Review of wound evaluation documentation dated February 16, 2022, revealed Resident 32 had a stage three pressure wound to the sacrum, which was not identified on the MDS assessment. Review of section M of the MDS assessment dated [DATE], indicated that Resident 32 did not have one or more areas of unhealed pressure ulcers/injuries. Review of wound evaluation documentation dated May 18, 2022, revealed Resident 32 had a stage three pressure wound to the sacrum, which was not identified on the MDS assessment. In an interview on July 8, 2022, at 11:07 a.m., the Director of Nursing confirmed that section M on the MDS assessment for Resident 32 was coded inaccurately and should have indicated a pressure ulcer/injury was present during the review period. Clinical record review revealed that Resident 19 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE], indicated that Resident 19 was not receiving hospice services while a resident in the facility. Further review of the clinical record revealed that Resident 19 enrolled in hospice services on July 14, 2021, which was not identified on the MDS assessment. In an interview on July 8, 2022, at 11:07 a.m., the Director of Nursing confirmed the MDS assessment was coded inaccurately and should have indicated Resident 19 remained on hospice services during the review period. 28 Pa. Code 211.5(f) Clinical records.

Based on clinical record review and observation, it was determined that the facility failed to ensure that a call bell was accessible for two of 17 sampled residents. (Residents 5, 20) Findings include: Clinical record review revealed that Resident 5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated July 29, 2021, revealed that the resident was able to communicate needs to staff and required extensive assistance from staff for activities of daily living. On August 17, 2021, at 10:21 a.m. and 11:22 a.m., the resident was observed in bed with the call bell on the floor out of reach. Clinical record review revealed that Resident 20 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated June 5, 2021, revealed that the resident required assistance with all activities of daily living. Review of the current care plan revealed that the resident required a soft touch call light. On August 17, 2021, at 10:55 a.m. and 11:34 a.m., the resident was observed in her wheelchair with the soft touch call bell draped over the oxygen concentrator behind the wheelchair out of reach. 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 ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's current status for one of 17 sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was sent out to the hospital on [DATE]. The MDS assessment dated [DATE], indicated in Section A that the resident was discharged with return anticipated. Review of a social services note dated [DATE], revealed that the resident had expired at the hospital. The facility failed to modify the MDS assessment to reflect that the resident was discharged and the return was not anticipated. In an interview on [DATE], at 9:40 a.m., the Director of Nursing stated that the facility failed to modify the MDS assessment in a timely manner to reflect the resident's status. 28 Pa. Code 211.5(f) Clinical records.

Based clinical record review and staff interview, it was determined that the facility failed to implement physician's orders and follow bowel protocol for one of 17 sampled residents. (Resident 207) Findings include: Review of facility policy entitled, Bowel Protocol dated January 2021, revealed that after 24 hours without a bowel movement (BM) staff should implement bowel protocol which included: Day one: prune juice was to be offered to the resident in the morning Day two: If the resident did not have a BM, Milk of Magnesia was to be offered. Clinical record review revealed that Resident 207 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On August 9, 2021, the physician ordered for staff to administer a medication for constipation (Milk of Magnesia) as needed by mouth for constipation. Review of Resident 207's BM task record for August 2021 revealed the resident had no BM on August 13, 2021, and August 14, 2021. Review of Resident 207's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on August 19, 2021, at 11:03 a.m., the Director of Nursing confirmed there was no documented evidence that Resident 207 was provided prune juice on August 13, 2021, day one without a BM, or Milk of Magnesia on August 14, 2021, day two without a BM, per facility bowel protocol. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy and observation it was determined that the facility failed to store medication in accordance with facility policy in one of one medication storage rooms. (Central medication storage room) Findings include: Review of the facility policy entitled, Storage of Medications, dated January 2021, revealed that outdated medications were to be immediately removed from stock and disposed of according to procedures for medication disposal. Observation of the medication refrigerator in the central medication storage room on August 18, 2021, at 10:59 a.m., revealed four boxes of Acetaminophen (Tylenol) suppositories with an expiration date of December 2020. 28 Pa. code 211.9 (i) Pharmacy services 28 Pa. code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to thoroughly investigate injuries of unknown origin for one of 18 sampled residents. (Resident 30) Findings include: Review of the facility policy entitled Resident Abuse, dated December 7, 2019, revealed that injuries of unknown origin were to be investigated by the interdisciplinary team to identify potential causes of the injury. Clinical record review revealed that Resident 30 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE], indicated that the resident utilized a wheelchair and transferred with extensive assistance from staff. A physcian's order dated April 12, 2018, revealed the resident was to have compression treatments with staff to apply wraps to both lower legs daily. Review of the nursing notes dated January 20, 2020, revealed that staff had transferred the resident from her wheelchair to the bed and noted blood on her right lower leg. At that time the wraps were removed revealing a laceration measuring 8 centimeters (cm) x 2 cm. There was no documented evidence that the facility completed a thorough investigation regarding the injury to determine the cause of the injury and to rule out abuse/neglect. In an interview conducted on February 21, 2020, at 10:15 a.m., the Director of Nursing confirmed that a thorough investigation had not been completed. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and documentation review, it was determined that the facility failed to follow safety interventions to prevent further accidents for one of seven residents identified at risk for falls. (Resident 29) Findings include: Clinical record reviewed revealed that Resident 29 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE], indicated the resident required assistance from staff for walking and transfers. Review of the ongoing care plan, indicated the resident was at high risk for falls related to deconditioning and required extensive assistance from staff with all transfers. A careplan intervention dated October 7, 2019, indicated that the resident was not to be left alone in the bathroom. Review of the nursing notes revealed that on November 25, 2019, at 9:00 p.m., Resident 29 had an unwitnessed fall in her bathroom. Further review of the nursing documentation indicated that staff had witnessed the resident standing alone at her sink in her bathroom prior to the fall. There was no documented evidence that staff had intervened as outlined in the care plan in order to prevent falls when Resident 29 was was observed alone in her bathroom. In an interview conducted on February 21, 2020, at 1:50 p.m., the Director of Nursing confirmed that staff had failed to implement assessed safety interventions to prevent the resident from falling. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observation it was determined that the facility failed to maintain sanitary conditions and store food properly in the kitchen. Findings include: Observation during the environmental tour of the nursing care services kitchen area on (MONTH) 26, 2019, at 9:58 a.m., revealed two bags of a whipped cream topping that had been opened and had not been dated or resealed properly. On the same day at 10:20 a.m., in the main kitchen observation revealed a frozen bag of okra in the walk in freezer that was not labeled or dated. Observation revealed a bag of sliced ham and a block of swiss cheese slices in a refrigerator that was not labeled or dated. In addition, the convection ovens were soiled with grease and food debris on the inside and outside of both of the top and bottom ovens. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 207.2(a) Administrator's Responsibility.

Based on clinical record review, policy review, observation and staff interview, it was determined that the facility failed to ensure that infection control practices were implemented to reduce the potential spread of infection for one of four sampled residents with an infection. (Resident 33) Findings include: Review of the facility's Isolation-Categories of Transmission-Based Precautions policy dated (MONTH) 14, (YEAR), revealed that staff were to implement contact precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Staff was to wear gloves and a disposable gown upon entering a resident's room who was on contact precautions. Clinical record review revealed that Resident 33 was readmitted to the facility on (MONTH) 15, (YEAR), with a [DIAGNOSES REDACTED]. On (MONTH) 15, (YEAR), the physician ordered that the resident be placed on contact precautions related to [MEDICAL CONDITION]. On (MONTH) 19, (YEAR), the physician ordered to maintain contact precautions for the resident. On (MONTH) 21, (YEAR), at 11:40 a.m. staff was observed entering the resident's room without gloves and without wearing a gown. The staff took the resident to the toilet and then proceeded to take the resident to the dining room. On (MONTH) 21, (YEAR), at 11:00 a.m. the Infection Control Preventionist confirmed that staff was to wear gloves and a disposable gown upon entering Resident 33's room. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, observation and staff interview, it was determined that the facility failed to implement care planned interventions for two of 21sampled residents. (Residents R30, R38) Findings include: Clinical record review revealed that Resident R30 had [DIAGNOSES REDACTED]. Review of the current plan of care revealed the resident was at risk for skin breakdown and impairment related to immobility. A current intervention was for staff to ensure that sheepskin covers were on both wheelchair arm rests at all times. Observations on (MONTH) 21, (YEAR), at 11:24 a.m. and again on (MONTH) 22, (YEAR), at 9:37 a.m. and 1:34 p.m, revealed that the resident was seated in her wheelchair without the sheepskin covering securely in place to cover the top of the left arm rest of the wheelchair. In an interview on (MONTH) 23, (YEAR), at 11:00 a.m. the Director of Nursing confirmed that the sheepskin covers were to be securely in place as an intervention to prevent skin tears. Clinical record review revealed that Resident R38 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated (MONTH) 29, (YEAR), indicated that the resident required supervision of one person and set up for her meals. Review of the current plan of care revealed a problem area of activities of daily living self care performance deficit related to dementia with limited range of motion and fatigue. A current intervention was for staff to set the resident up for meals and assist her to eat as needed. Observation on (MONTH) 21, (YEAR), from 1:00 through 1:25 p.m. revealed that the resident was seated at a table in the dining room with three other residents. Resident R38 was experiencing difficulty eating her meal. Her head was dropping down onto her chest. The resident had her spoon in her hand but was unable to eat with it and the pureed soup and chili had spilled out onto the table. The resident did not eat much of her meal and did not receive assistance from staff as care planned. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on clinical record review, review of current facility policy, observations, and staff interview, it was determined that the facility failed to ensure that staff properly stored equipment used in the cleaning of urinary drainage bags and failed to ensure that staff cleaned urinary drainage bags adequately and in accordance with facility policy for three of four residents who used urinary drainage bags. (Residents R4, 29, and 35) Findings include: Review of current facility policy entitled Care and Cleaning of Urinary Leg Bag, dated March 4, 2016, revealed that when the leg bag was not in use, staff was to clean it with a mixture of vinegar and water. (Urinary drainage bags are used with indwelling urinary catheters, to hold urine that drains from the resident's bladder. An indwelling urinary catheter is a tube that is inserted into the resident's bladder. The catheter is then attached to a urine drainage bag. There are different types of drainage bags. A standard urine drainage bag refers to a bag with attached tubing. The bag can hold two or three liters of urine. Another type of urinary drainage bag is called a leg bag. It is smaller than the standard drainage bag. A leg bag is typically used when the resident is out of bed. It is connected to the urinary caterer and then secured to the resident's leg. It allows for ease of movement and also is easier to conceal beneath the resident's clothes. Some residents with indwelling urinary catheters use a standard urine drainage bag when in bed and a leg bag when out of bed. In an interview on November 16, 2016, at 11:30 AM, the director of nursing confirmed that staff were to use the vinegar and water solution, referred to in the policy noted above, to clean both types of bags.) Clinical record review revealed that Resident R35 had been readmitted to the facility on [DATE]. A Minimum Data Set quarterly review assessment (a periodic assessment of resident needs) dated August 11, 2016, reflected that the resident was cognitively impaired anmd was dependent on staff for toileting and hygiene. Physician orders [REDACTED].) These physician orders [REDACTED]. On November 16, 2016, at 10:45 AM and again at 11:50 AM, the resident was observed dressed and out of bed. His standard urine drainage bag was draped on the towel bar in the resident's bathroom. In an interview at 11:50 AM that day, Employee 1, the nurse aide assigned to the resident, said she had cleaned the urine drainage bag with soap and water only, and had not used vinegar because there was none in the resident's room. Clinical record review revealed that Resident 4 was admitted to the facility on [DATE], with a suprapubic indwelling urinary catheter. Physician orders [REDACTED]. There was a lack of evidence that staff cleaned the urine drainage bags in accordance with facility policy. A review of the November 2016 Task Care Sheet revealed that there was no documentation to support that staff had cleaned the drainage bags prior to November 7, 2014, three days after the resident was admitted . On November 16, 2016, at 11:35 AM, a jug of vinegar used in the cleaning of the urine drainage bags, was observed stored directly on the floor in the resident's bathroom. The Director of Nursing, who was present during this observation, confirmed that staff should not have placed the vinegar contained directly on the floor. Clinical record review revealed that Resident R29 was readmitted to the facility on [DATE]. A Minimum Data Set quarterly review assessment dated [DATE], reflected that the resident was dependent on staff for assistance with toileting and hygiene. The resident's care plan, dated September 8, 2016, reflected that the resident had a suprapubic indwelling urinary catheter and that he was at risk for infection. Physician orders [REDACTED]. On November 16, 2016, from 2:20 PM to 2:30 PM, a jug of vinegar used in the cleaning of the urine drainage bags was observed stored directly on the floor in the resident's bathroom. Also the resident:s standard urinary drainage bag was observed stored in a plastic basin which was on the bathroom floor beside the toilet. A portion of the tubing of the drainage bag was outside the basin and resting directly on the floor. 28 PA Code 211.10(d) Resdent care policies. 28 PA Code 211.12 (d)(5) Nursing services.

Based on observation during the environmental tour of the food service department and staff interview, it was determined that the facility failed to maintain sanitary conditions. In addition, the facility failed to ensure that thickened beverages were stored according to the manufacturer's specifications. Findings include: Observation during the environmental tour on February 19, 2014, at 10:11 a.m., revealed dirty water in the floor drain (trough type) of the cart washing room. In the potwashing area the walls, exit door and shelving was soiled with dried on food debris. The filter of the ice machine was coated with dust and areas of floor tile were stained. Review of the manufacturer's specifications on the product label of the thickened beverages revealed that the beverages were to be discarded if not used within five days from the date opened. Observation on the nursing unit revealed four nectar thickened beverage containers that were opened, but not dated. During an interview on February 21, 2014, at 9:25 a.m., the Purchasing Manager confirmed that the opened containers should have been labeled with an open and use by date.

Based on clinical record review and staff interview, it was determined that the facility failed to implement physician ordered nutritional interventions to ensure that nutritional parameters such as body weight were maintained for one of seven residents identified at nutritional risk. (Resident R72) Findings include: Clinical record review revealed that Resident R72 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident received nutrition and hydration through a feeding tube (PEG tube). A Minimum Data Set assessment dated [DATE], identified that the resident received a mechanically altered diet with additional calories and fluids provided via the tube feeding. The care plan dated October 2012, identified that the resident was at nutritional risk and directed staff to provide tube feeding as ordered by the physician. On January 22, 2013, the physician ordered staff to provide the resident with 240 milliliters of a nutritional supplement via tube feeding at 8:00 p.m., daily. Review of February and March 2013 Medication Administration Records revealed that staff failed to provide the 8:00 p.m., tube feeding in accordance with the physician's orders [REDACTED]. On February 28, 2013, the physician ordered that dietary staff complete a three day calorie count. As of 7:30 a.m., on March 6, 2013, there was no evidence that a calorie count was started for the resident. In an interview on March 6, 2013, at 7:45 a.m., the Registered Dietitian confirmed that Resident R72 had not received the tube feeding per physician's orders [REDACTED]. 28 Pa. Code 211.12(d)(1)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/25/12