Every finding on record at Jameson Nursing and Rehab Center

Based on review of facility policy, manufacturer's guidelines, observations, and staff interview, it was determined that the facility failed to ensure that medications were properly dated when opened, in one of two medication rooms reviewed (A Hall medication room). Findings include: Review of a facility policy entitled Storage of Medications with a policy review date of 1/5/2026, revealed that, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Manufacturer's guidelines for Aplisol PPD (solution used for tuberculosis testing upon admission and for employment), indicated that, vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Observation on 2/26/26, at 11:35 a.m. of the A hall medication room refrigerator revealed an opened vial of Aplisol PPD without an open date, therefore the staff were unable to determine the discard date. During an interview at that time, the Licensed Practical Nurse Employee E1 confirmed that the opened Aplisol PPD vial lacked an open date, and staff were unable to determine the discard date. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, review of clinical records and staff interviews, it was determined that the facility failed to administer a medication per physician's orders for one of 19 residents reviewed (Resident R227). Findings include: Resident R227's clinical record revealed an admitted [DATE], with diagnoses that included fracture of the right hip, arthritis, anxiety disorder, and Type 2 diabetes (a long term condition in which the body has difficulty controlling blood sugar and using it for energy.) Resident R227's clinical record revaled a physician's order for Janumet (an anti-diabetic medication that can treat Type 2 diabetes) Oral tablet 50/500 mg (milligrams) by mouth two times per day with a start date of 2/19/25 at 8:30 a.m. Observation of medication administration on 2/19/25, at approximately 8:55 a.m. with Licensed Practical Nurse (LPN) Employee E1, revealed that Resident R227's medication Janumet 50/500 mg one tablet by mouth two times per day, was not available to be administered. LPN Employee E1 stated that Resident R227 was a new admission and the medication had not come from the pharmacy and when the medication arrives, it will be administered. There was no evidence of follow-up with the physician and the orders for the resident regarding the medication being unavailable/not administered. Review of Resident R227's progress notes on 2/20/25 at approximately 2:00 p.m. revealed that Resident R227 missed doses of Janumet 50/500 mg that included on 2/19/25,the morning and evening doses and on 2/20/25, for the morning dose. During an interview on 2/20/25, at approximately 3:15 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to administer Janumet as ordered upon admission to the facility and Resident R227 missed three doses of the medication Janumet since admission to the facility. 28 Pa. Code 211.5(f)(i)(ii)(iii) Medical records 28 Pa. Code 211.9(d) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and staff interviews, it was determined that the facility failed to transcribe physician's orders for an anticoagulant (medication to thin your blood to prevent blood clots) medication and dressing change to a surgical incision for one of four residents reviewed (Resident R1). Findings include: Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included anemia (a reduction in red blood cells resulting in symptoms such as fatigue and weakness), atelectasis (when part or your entire lung collapses resulting in symptoms such difficulty breathing, wheezing, and cough), and fractured right hip. Resident R1's clinical record contained a document from an area hospital entitled Patient Summary dated 10/25/24, which identified a list of medications Resident R1 was to continue while at the facility. The Patient Summary indicated that Resident R1 was ordered Lovenox (injectable anticoagulant medication) 40 milligram (mg) per 0.4 milliliters (ml) - give 0.3 ml subcutaneous (sq) daily for 30 days. Resident R1's physician's orders and Medication Administration Record (MAR) lacked evidence that the facility transcribed and administered Lovenox as ordered on 10/26/24 and 10/27/24. During an interview on 11/26/24, at approximately 2:15 p.m. the Nursing Home Administrator confirmed the facility failed to transcribe Resident R1's admission orders to include Lovenox resulting in the Lovenox not being administered as ordered. Resident R1's clinical record also contained a document from an area hospital entitled Ortho - Final Progress dated 10/25/24, that revealed under Incision / Wound Care that Resident R1 was to have a dry dressing change completed daily until completely dry for two days, then it was okay to leave incision open to air. Review of Nurse to Nurse Admission Report revealed the area hospital informed the facility that Resident R1 had a dressing to her leg. Review of Resident R1's Admission Assessment completed by the facility on 10/25/24, Section I entitled Skin Condition and History revealed a right thigh surgical incision with two dressings present. Review of Resident R1's physician's orders and Treatment Administration Record (TAR) lacked evidence that the facility transcribed and changed the right hip dressing as ordered. During an interview on 11/26/24, at approximately 3:00 p.m. the Director of Nursing confirmed the facility failed to transcribe the dressing change order regarding Resident R1's right hip and failed to provide evidence that if clarification was needed, that the facility contacted the primary care physician and/or surgeon to obtain clarification so care could be provided. 28 Pa. Code 211.5(f)(i)(ii) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies, facility documentation, and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure residents were free from neglect for one of 14 residents reviewed (Resident R1). Findings include: Review of facility policy entitled Abuse and neglect clinical protocol Revised March 2018, revealed Neglect: The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of facility policy entitled Falls-Clinical Protocol Revised March 2018, revealed Falls should be categorized by: those that occur while trying to rise from a sitting or lying to a standing position, those that occur while upright and attempting to ambulate, and other circumstances such as sliding out of a chair or rolling from a low bed to the floor. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included fracture of the head and neck of the left femur, atrial fibrillation (irregular heart beat), and heart failure. Review of Resident R1's Quarterly Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) assessment dated [DATE], revealed under section G transfers, that Resident R1 required extensive assistance with transfers. Review of Resident R1's Care Plan revealed that the resident was an assist of two with transfers, resident was non-weight bearing. Review of information submitted by the facility dated 8/21/2024, revealed Resident R1 was incorrectly transferred by one employee after receiving a shower in the shower room and was lowered to the floor resulting in a fall to him/her. Review of the facility's investigation revealed an employee statement by Nurse Aide (NA) Employee E1 that identified that NA Employee E1 confirmed on 8/21/24, at about 8:10 p.m. he/she transferred Resident R1 to the shower with Employee E2 and Resident R1 was then assisted onto the shower chair. The shower was completed. Resident R1 apparently kept leaning forward during the shower. Employee E1 then stated, helped her stand and tried to pull lounge chair behind her. It would not move very well, so I yelled four times I need help in here. No one came so I had to lower her to the floor and came out to get help. Review of NA Employee E2's statement revealed, This aid helped get Resident on shower chair and helped get her into shower. This aid told the aid to let any of us know to help get her back in to the chair after the shower. This aid proceeded to leave shower room to change and get into bed a resident. This aid proceeded to stay at nurse's station to wait for aid to say they were done. Aid finally opened door for help and this aid went to help when this aid opened door, this aid saw resident sitting on the floor. Four people went in to help get her into her chair. [He/she]stated [he/she] yelled for help four times, but we were all at the nurse's station and did not hear anything. Review of Registered Nurse (RN) Supervisor Employee E3's statement revealed that the resident was being showered in shower room; Employee E1 did not ask for assistance and did not hit the call bell in shower room for assistance; He/she stated he/she lowered the resident to the floor; and the resident was found on tile floor and was assessed. Review of documentation submitted by the facility dated 8/23/24, revealed that the facility initiated an investigation, regarding resident neglect. NA Employee E1 was suspended from work during the investigation process. NA Employee E1 was terminated from work on 8/27/24, due to failing to follow the resident plan of care resulting in resident suffering a fall in the shower room. Employee Education was conducted. During an interview on 10/02/24, at 12:30 p.m. the Nursing Home Administrator (NHA) confirmed that NA Employee E1 transferred Resident R1 by physically lifting him/her and not obtaining assistance of two people resulting in a fall in the shower with no harm or injury to Resident R1. He/she also confirmed that the resident should have been transferred as care planned with the assist of two people to a wheelchair. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to maintain resident dignity for one of one residents with an indwelling catheter (a tube inserted into the bladder to drain urine) (Resident R3). Findings include: Review of Resident R3's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R3's active care plan revealed an intervention related to an indwelling catheter to cover the catheter bag for privacy/dignity when appropriate. Observations on 5/04/22, through 5/06/22, revealed Resident R3's indwelling catheter bag hanging from the resident's bed uncovered exposing the bag with urine to be viewed easily by all who pass by in the hallway. During an interview on 5/05/22, at 12:05 p.m. Registered Nurse Employee E1 confirmed that Resident R3's indwelling catheter bag was hanging from the bed filled with urine and should be covered. During an interview on 5/05/22, at 12:50 p.m. the Director of Nursing confirmed that Resident R3's indwelling catheter bag should always be covered to maintain privacy/dignity for the resident. 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to assure a physician's order was completed to indicate the code status as Full Code (CPR/Attempt Resuscitation) or Do Not Resuscitate (DNR/Do Not Attempt Resuscitation-Allow Natural Death) for three of 16 residents reviewed (Residents R5, R11, and R28). Findings include: A facility policy entitled Physician's Orders for Life Sustaining Treatment (POLST) reviewed by the facility on [DATE], indicated if a resident is admitted with a completed POLST form, the POLST will be entered into the Electronic Health Record (EHR), once reviewed and confirmed by the resident's nurse as a Physician's Order. In addition, the policy indicated if a resident is admitted without a POLST, once reviewed and confirmed, the POLST will be entered into the EHR as a Physician Order. Review of Resident R5's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R5's clinical record lacked a physician's order to indicate a code status as Full Code or DNR. Review of Resident R11's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R11's clinical record lacked a physician's order to indicate a code status as Full Code or DNR. Review of Resident R28's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R28's clinical record lacked a physician's order to indicate a code status as Full Code or DNR. During an interview on [DATE], at 1:30 p.m. the Director of Nursing confirmed that Residents R5, R11, and R28's clinical records lacked a physician's order to indicate a code status as Full Code or DNR and the facility's policy was to enter the POLST into the EHR as a physician's order. 28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility infection control records and staff interview, it was determined that the facility failed to track and trend (ongoing process to help identify and manage any infection to help prevent spread) infection information in the facility in a manner enabling identification of outbreaks or clusters of infection and help prevent spread of infections. Findings include: A review of the facility's infection control monitoring records revealed the facility lacked an ongoing process to identify, track and trend infections based on causative organism and type of infection per each facility unit or staff assignment blocks since January 2021. During interview on 7/07/21, at 10:20 a.m., the Nursing Home Administrator confirmed that the current infection control records did not include tracking and trending of infections based on infectious organisms, type of infection or location to help prevent the spread of any infection in the facility since January 2021. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on observations and staff interview, it was determined the facility failed to maintain privacy of confidential information during medication administration for one of two wings (B Wing). Findings include: Observation on 10/10/19, at 11:29 a.m. revealed Licensed Practical Nurse (LPN) Employee E1 performing resident medication administration and left the medication cart and the computer screen open with resident information visible to anyone passing by in the corridor. During an interview at the time of the observation, LPN Employee E1 acknowledged the lack of privacy with resident information on the computer screen. Observation on 10/10/19, at 12:28 p.m. revealed two medication carts along side B Wing nurses station not attended to by staff with both computer screens open and visible to anyone passing by in the corridor. 28 Pa. Code 211.5(b) Clinical records

Based on review of the Minimum Data Set (MDS-federally-mandated assessments of a resident ability and care needs) User's Manual, clinical records and staff interviews, it was determined that the facility failed to ensure that the MDS assessments were completed within the required time frame for two of 19 residents reviewed (Residents R7 and R22). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing MDS assessments, dated (MONTH) (YEAR), indicates that the Assessment Reference Date (ARD-the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type and is to be completed no later than the ARD plus 14 calendar days. Resident R7's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R7's MDS records revealed that a Quarterly MDS had an ARD of 5/29/19, with no additional MDS scheduled or completed for a period of 134 days after the previous assessment and 42 days past due. Resident R22's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R22's MDS records revealed that a Quarterly MDS had an ARD of 5/26/19, with no additional MDS scheduled or completed for a period 137 days after the previous assessment and 45 days past due. During an interview on 10/9/19, at 10:45 a.m. Registered Nurse Assessment Coordinator Employee E2 confirmed that Residents R7 and R22 MDS assessments were not completed within the required time frame. 28 Pa. Code 211.12 (c)(d)(5) Nursing services Previously cited 11/15/18

Based on review of clinical records, facility policies, and staff interviews, it was determined that the facility failed to develop and/or update individualized care plans for four of 19 residents (Residents R38, R40, R52, and R68). Findings include: The Comprehensive Care Plans policy, dated 9/24/19, indicated that care plans should be updated as the resident's status changes. Resident R38's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Clinical notes indicated that Resident R38 fell on [DATE] and 2/12/19. Resident R38's care plan entitled Risk for Falls created on 5/28/19, revealed that the facility failed to develop a care plan to address Resident R38's falls until 5/28/19. Resident R40's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Clinical notes indicated that Resident R40 fell on [DATE] and 9/10/19. Resident R40's care plan entitled History of Falls created on 8/2/18, revealed that the facility failed to update the care plan with new interventions following the incidents on 9/9/19 and 9/10/19. Resident R52's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Clinical notes indicated that Resident R52 fell on [DATE], 4/29/19, 8/24/19, 9/1/19, 9/9/19, and 9/10/19. Resident R52's care plan entitled Risk for Falls created on 11/19/17, revealed that the facility failed to update the care plan with new interventions following the incidents on 4/21/19, 4/29/19, 8/24/19, 9/1/19, 9/9/19, and 9/10/19. Resident R68's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Clinical notes indicated that Resident R68 fell on [DATE], 6/12/19, 6/23/19, 7/24/19, 8/6/19, 8/17/19, 9/6/19, and 9/7/19, sustained a skin tear while transferring on 5/26/19, and a bruised, swollen hand on 5/17/19. Resident R68's care plan entitled Risk for Falls created 6/27/17, revealed that the facility failed to update the care plan with new interventions following the incidents on 3/30/19, 6/12/19, 7/24/19, 8/17/19, 9/6/19, 9/7/19, 5/26/19, and 5/17/19. During an interview on 10/09/19, at 1:45 p.m., Registered Nurse Employee E3 confirmed that the fall care plans were not initiated and/or updated for Residents R38, R40, R52, and R68. 28 Pa. code 211.5(f) Clinical records 28 Pa Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 11/15/18

Based on observations, review of facility policy and staff interviews, it was determined that the facility failed to properly clean and prevent the potential for cross contamination during the use of a blood glucose meter (BGM-a device to collect and measure the level of glucose (sugar) in the blood) for two of 19 residents observed during the administration of medications (Residents R41 and R225). Findings include: The facility policy entitled Blood Glucose Meter dated 9/24/19, indicated that staff are to clean the meter before and after each resident use, utilizing a Sani-Cloth wipe per manufacturer's recommendation. Observation on 10/7/19, at 3:52 p.m. revealed that Licensed Practical Nurse (LPN) Employee E3 removed the BGM from the case without cleaning it, he/she proceeded to obtain a blood glucose sample from Resident R41. LPN Employee E3 then laid the BGM on top of the medication cart without cleaning it. At 3:56 p.m. he/she then proceeded to take the same BGM and obtained a blood glucose sample from Resident R225. LPN Employee E3 then replaced the BGM into the case at the nurse's station without cleaning it. During an interview on 10/7/19, at 4:00 p.m. LPN Employee E3 indicated that night shift cleans the BGM's and performs the Quality Control checks every night. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services Previously cited 11/15/18

Based on observations and staff interview, it was determined that the facility failed to maintain a clean and sanitary homelike environment in 14 of 46 resident bathrooms (Rooms 3, 5, 6, 8, 12, 14, 18, 20, 36, 41, 42, 43, 56 and 58) Findings include: room [ROOM NUMBER]-toilet was continually running room [ROOM NUMBER]- resident used towels were hanging on the grab rail next to the toilet room [ROOM NUMBER]- resident used towels were hanging on the grab bars next to the toilet room [ROOM NUMBER]- paper on the floor, the latch to the bathroom door was taped so the door would not latch, toilet riser had chipped paint and what appeared to be rust room [ROOM NUMBER]- rubber base molding at the bottom of the wall was missing room [ROOM NUMBER]-brown stain around the bottom of the toilet, floor was sticky room [ROOM NUMBER]- brown dried stains on the riser toilet seat, dirty washcloths left out on the shower chair room [ROOM NUMBER]-brown stains around the toilet, brown stains on the floor on entry into the bathroom room [ROOM NUMBER]-dirty towels on the floor, toilet was running room [ROOM NUMBER]- pipe on the floor, black stains on the front of the toilet room [ROOM NUMBER]-toilet seat not sitting on toilet straight, no bag in the wastebasket, wall paper in the bathroom was torn room [ROOM NUMBER]- prior to staff cleaning the room, noted paper and plastic cup in corner of bathroom on the floor, brown stain in the toilet, brown streak down the front of the toilet and hair noted on the outside of the toilet, after cleaning- paper and plastic medicine cup on the floor in the corner of the bathroom, brown stain and hair still on the front of the toilet, call bell cord dirty room [ROOM NUMBER]- brown stain around the bottom of the toilet room [ROOM NUMBER]- toilet riser paint cracked and rusty During an interview on 7/23/19, between 11:00 a.m. and 11:10 a.m. the Director of Nursing confirmed the above findings. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 11/15/18 28 Pa. Code 201.18(e)(1) Management Previously cited 11/15/18 28 Pa. Code 207.2(a) Administrator's responsibility Previously cited 11/15/18

Based on observations and staff interview, it was determined that the facility failed to maintain a sanitary environment to prevent the spread of infection in 14 of 46 resident bathrooms (Rooms 8, 16, 23, 36, 41, 42, 43, 44, 45, 47, 48, 49, 55 and 56). Findings include: Observations of resident bathrooms on 7/23/19, from 9:30 a.m. through 10:50 a.m. revealed that following: room [ROOM NUMBER]- a toilet cover on the floor room [ROOM NUMBER]- a bed pan on the floor and wash basin on the floor room [ROOM NUMBER]-call bell cord on floor and dirty room [ROOM NUMBER]-towels on the floor, wheelchair foot rests on the floor room [ROOM NUMBER]-drain pipe left on the floor, dirty call bell cord room [ROOM NUMBER]-no bag in the wastebasket room [ROOM NUMBER]-dirty call bell cord room [ROOM NUMBER]-call bell cord on the floor room [ROOM NUMBER]-wash basin on the floor room [ROOM NUMBER]-wash basin on the floor, wheelchair foot rests on the floor room [ROOM NUMBER]-wash basin on the floor room [ROOM NUMBER]-bedpan on the floor, bag of aloe wipes on the floor room [ROOM NUMBER]-wheelchair foot rests on the floor room [ROOM NUMBER]-wheelchair foot rests on the floor, bedside commode pan on the floor During an interview on 7/23/19, between 11:00 a.m. and 11:10 a.m. the Director of Nursing confirmed that the foot rests should not be stored on the floor, the call bells should not be on the floor or dirty, there should be garbage bags in the garbage bins, and that the wash basins, bed pans and towels should not be on the bathroom floors. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 11/15/18 28 Pa. Code 201.18(e)(1)(3) Management Previously cited 11/15/18 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 11/15/18

Based on a review of facility policy, observations and staff interview, it was determined that the facility failed to properly cool food products, prepare food, and properly wash, rinse and sanitize serving dishes which created the potential for cross contamination in the Main Kitchen (Main Kitchen). Findings include: A review of facility Food Storage policy dated 10/10/18, indicated that the facility will store, prepare, distribute and serve food under sanitary conditions to prevent foodborne illness. During an observation of tray line preparation on 11/13/18, at 5:06 p.m. Dietary Aide (DA) Employee 2 was placing servings on the plates. For each entrée, DA Employee 2 leaned forward to read the menu sheet, allowing her soiled shirt front and identification badge to rest in the plate, prior to the food being placed on it. During an interview on 11/13/18, at 5:20 p.m. Dietary Manager Employee 1 confirmed that allowing clothing and the identification badge to touch the resident's plates created the potential for cross contamination. During an observation of the dish room on 11/13/18, at 6:00 p.m. it was revealed that Dietary Aide Employees E3 failed to remove her soiled apron when moving from the clean side to the dirty side and failed to have glassware and bowls rewashed that was filled with water and laying on their side at the end of the wash cycle. During an interview on 10/13/18, at 6:20 p.m. Dietary Aide Employee E3 confirmed that the facility failed to properly wash, rinse, sanitize and store serving dishes and separate dirty and clean areas which created the potential for cross contamination. Pa Code: 211.6(c)(f) Dietary services.

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents for four of four residents (Resident R44, R11, R22 and R31). Findings include: A review of the facility policy Abuse dated 10/10/18, indicates staff reports any suspicious occurrences and all bruises or injuries. Investigations are conducted to thoroughly determine possible causes. A review of a nurse progress note dated 8/5/18, indicated resident R44 had purple discoloration completely around the right eye. A review of a nurse progress note dated 8/6/18, indicated resident R44 has bruised right eye. A review of the facility Accident Investigation Reports for (YEAR), did not include a report or investigation for Resident R44's bruised right eye. A review of a nurse progress note dated 11/12/18, indicated that Resident R11 returned from an activity with a small cut above her right eyebrow in the shape of a fingernail which require a treatment. A review of the facility Accident Investigation Reports for (YEAR), did not include a report or investigation for Resident R11's cut above her right eyebrow. A review of a nurse progress note dated 8/20/18, indicated that Resident R22's right lower leg was bumped and was bruised and cut which required treatment. A review of the facility Accident Investigation Reports for (YEAR), did not include a report or investigation for Resident R22's cut/bruise of her right lower leg. A review of a nurse progress note dated 8/28/18, indicated that Resident R22 had a dressing change to her right lower leg with Xeroform gauze and [MEDICATION NAME] border gauze indicating a wound. A review of the facility Accident Investigation Reports for (YEAR), did not include a report or investigation for Resident R22's injury of right lower leg was investigated or was wound from previous injury that had worsened. A review of a nurse progress note dated 10/1/18, indicated that Resident R31 had a large bruise of her right lateral foot. A review of the facility Accident Investigation Reports for (YEAR), did not include a report or investigation for Resident R31's injury of right lateral foot. During an interview on 11/14/18, at 4:45 p.m. the Director of Nursing confirmed that facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents for Resident R44, R11, R22 and R31. 28 Pa. Code: 201.14(a) Responsibility of Licensee. 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 201.20(a)(b) Staff development. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, observations, and interview with staff, it was determined that the facility failed to make certain the resident environment remains free of accident hazards and each resident receives adequate supervision and assistance to prevent accidents for five of five residents (Resident R42, R36, R12, R26 and R31). Findings include: A review of the facility policy Preventable Serious Adverse Events dated 10/10/18, indicated the facility focuses on patient safety and quality. A review of the clinical record revealed that Resident R42 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the clinical record revealed that Resident R36 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the quarterly MDS dated [DATE], indicates severely cognitively impaired. A review of the clinical record revealed that Resident R12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the quarterly MDS dated [DATE], indicates severely cognitively impaired. During an observation on 11/13/18, at 2:15 p.m. of the B wing dining lounge revealed the oven to be turned on and set at 350 degrees. The door to the dining lounge was open and unsecured to other residents. Residents R42, R36 and R12 were in the dining lounge and no staff were present. During an interview on 11/13/18, at 2:15 p.m. Certified Nursing Assistant (CNA) Employee E6 confirmed that the oven was turned on in the B wing dining lounge. The door to the dining lounge was open and unsecured to other residents, and Resident R42, R36 and R12 were in the lounge and no staff were present. Review of a clinical record revealed that Resident R26 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the annual MDS dated [DATE], indicated Resident R26 has a BIMS of 1 which indicates cognitive impairment. Review of a clinical record revealed that Resident R31 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the quarterly MDS dated [DATE], indicated Resident R31 has a BIMS of 6 which indicates cognitive impairment. During an observation on 11/13/18, at 1:00 p.m. of the A wing dining lounge revealed the oven to be turned on and set at 350 degrees. The door to the dining lounge was open and unsecured to other residents. Resident R26 and R31 were in the dining lounge and no staff were present. During an interview on 11/13/18, at 1:10 p.m. Registered Nurse (RN) Employee E5 confirmed that the oven was turned on in the A wing dining lounge. The door to the dining lounge was open and unsecured to other residents, and Resident R26 and R31 were in the lounge and no staff were present. During an interview on 11/13/18, at 2:35 p.m. the Director of Nursing (DON) confirmed that the facility failed to make certain the resident environment remains free of accident hazards and each resident receives adequate supervision and assistance to prevent accidents for Resident R42, R36, R12, R26 and R31. 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 facility policy and clinical record review and staff interview, it was determined that the facility failed to make certain that residents receiving [MEDICAL CONDITION] drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and identification of the behavioral symptoms being treated are documented in the clinical record for two of five residents (Resident R12 and R49). Findings include: A review of the facility policy [MEDICAL CONDITION] Drug Managementdated 10/10/18, indicates the use of [MEDICAL CONDITION] medications will be thoroughly documented in the clinical record to include an appropriate supporting [DIAGNOSES REDACTED]. A review of the clinical record revealed that resident R12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a physician order dated 10/26/18, indicated to give [MEDICATION NAME] (an anti anxiety medication) 0.5 mg (milligrams) 1/2 tablet every six hours as needed. A review of the Medication Administration Record [REDACTED]. The clinical record did not include documentation to identify the behavioral symptoms being treated. A review of the clinical record revealed that resident R49 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a physician order dated 9/14/18, indicated to give [MEDICATION NAME] 0.5 mg as needed two times daily. A review of the MAR indicated [REDACTED]. The clinical record did not include documentation to identify the behavioral symptoms being treated. During an interview on 11/15/18, at 10:50 a.m. Licensed Practical Nurse (LPN) Employee E4 confirmed the above findings and that the facility failed to make certain that residents receiving [MEDICAL CONDITION] drugs are not given these drugs unless the medication is necessary to treat a specific condition and identification of the behavioral symptoms being treated are documented in the clinical record for Residents R12 and R49. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to prevent the potential for cross contamination in one of one kitchens (Main Kitchen). Findings include: The facility Hand Protection policy dated 10/16, instructed dietary staff to apply a new pair of gloves when changing tasks, and after handling ready to eat foods such as sandwiches. During an observation on 10/4/17, from 11:44 a.m. to 12:35 p.m. the following was observed during tray line: Hot Cook #1(HC) Employee E7 served food from the steam tables, left the position several times, picked up dirty stained pot holders, went to the oven, opened the oven doors, removed a baked potato and then returned to the steam table to continue to serve food. When a grilled cheese sandwich needed to be made, Employee E7 left the tray line again, opened a cooler and unwrapped two pieces of bread, buttered each piece, turned on the stove, placed bread in the pan, adjusted the pan by touching the handle and returned to the tray line to serve hot foods. Employee E7 continued to touch plates and serving utensils without performing glove changes or hand hygiene when changing tasks. An unidentified kitchen employee was observed going into the cooler where bread is stored with ungloved hands. Hot Cook #2 Employee E8 walked around the kitchen with gloved hands and returned to the tray line to assist HC Employee E7. HC Employee E8 opened the oven, removed plates that were being kept warm and placed plates on the tray line. Another grilled cheese sandwich needed prepared and HC Employee E8 went to the cooler door, opened the door, removed bread, unwrapped two pieces of bread, buttered each piece, placed buttered bread in the pan, then returned to the tray line to assist HC Employee E7. All task were preformed while failing to perform glove changes or hand hygiene. At the end of the tray line an unidentified kitchen employee who was taking carts to the nursing unit was seen removing gloves from her pocket and using those gloves for taking trays off tray line and placing them in the cart for delivery to the units. During an interview on 10/4/17, at 12:50 p.m. Dietary Manager Employee E2, Hot Cook Employee E7 and Hot Cook Employee E8 confirmed that the facility failed to prevent the potential for cross contamination when they failed to perform hand hygiene and change gloves during tray line tasks while handling food and touching various kitchen surfaces. 28 Pa. Code: 211.6 (c) (f) Dietary services.

Based on facility policy, observation and staff interviews, it was determined that the facility failed to provide a dignified dining experience for 10 of 17 residents (Resident R16, R17, R18, R19, R20, R21, R22, R52, R56 and R58) and failed to provide privacy during a dressing change for one resident (Resident R7) Findings include: A review of the Resident Rights, given to residents upon admission, indicated that residents have a right to be treated with dignity and respect. During a group interview on 10/3/17, at 10:00 a.m. Resident R52, R56 and R58 indicated that sometimes residents have to wait a long time to be served meals in the dining room. During an observation of the main dining room on 10/2/17, from 5:15 p.m. to 5:50 p.m. residents seated together at a table were served dinner at the following times: Resident R17 was served at 5:25 p.m Resident R18 was served at 5:25 p.m. Resident R19 was served at 5:45 p.m. Resident R20 was served at 5:46 p.m. Resident R21 was served at 5:47 p.m. Resident R22 was served at 5:48 p.m During an observation of the main dining room on 10/2/17, at 5:35 p.m. Resident R17 expressed concern that some of the other residents at her table didn't have their food, while she already had her meal. During an interview on 10/2/17, at 5:55 p.m. Nurse Aide (NA) Employee E9 confirmed that residents at the same table were served at different times. During an observation on 10/2/17, at 5:27 p.m. in the A wing Dining Room, NA Employee E6 was observed standing over Resident R16 while feeding him. During an interview on 10/2/17, at 5:33 p.m. Licensed Practical Nurse (LPN) Employee E5 confirmed that Resident R16 was not provided a dignified dining experience while NA Employee E6 fed him while standing. A review of clinical records dated 10/17, indicated that Resident R7 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of facility policy Wound Dressing Change dated 10/16, indicated that privacy should be provided during the procedure. During a dressing change observation on 10/3/17, from 10:58 a.m. through 11:14 a.m. Resident R7 was rolled to the left side and held in position by LPN Employee E10 while Infection Control Registered Nurse (RN) Employee E4 performed the dressing change. Resident R7 was in a shared room, and the privacy curtain was left open exposing Resident R7's buttocks area to anyone who entered. Resident R7's roommate had visitors in her room at the time of this dressing change. During an interview on 10/3/17, at 11:15 a.m. Infection Control RN Employee E4 confirmed that a dignified dressing change experience was not afforded to Resident R7 when the privacy curtain was left open. Pa Code: 201.29(j) Resident Rights. Previously cited 11/18/16. 28. Pa Code: 211.12(d)(1)(5) Nursing Services. Previously cited 11/18/16.

Based on facility policy, observation and interview, it was determined that the facility failed to safely store, label and date medications and biologicals on two of two nursing units (A Wing and B Wing nursing unit). Findings include: A review of the facility policy Vials and Ampules of Injectable Medications dated 10/20/16, indicated that multi-dose vials must be dated and initialed on first entry. Tuberculin skin testing serum should be dated and timed on the vial when opened and the vial should be discarded in 30 days. A review of the facility policy Medication Labels dated 10/20/16, indicated that the provider pharmacy permanently affixes labels to the outside of prescription containers, and that medication labels are not altered, modified, or marked in any way by nursing personnel. Improperly or inaccurately labeled medications are rejected and returned to the supplier. A review of the Medication Storage in the Facility and Temperatures and Cleaning of Refrigerators and Microwaves policies dated 10/20/16, indicated that medications requiring refrigeration are kept in the refrigerator at temperatures between 36 and 46 degrees F (Fahrenheit) and with a thermometer to allow temperature monitoring. If the temperature of a medication refrigerator is out of range, the reverse side of the Medication Refrigerator Temperature Log will be completed. Information required includes the date and time the temperature discrepancy was noted, a listing of the medications in the refrigerator at that time, and notification of the pharmacy. During an observation on 10/2/17, at 12:51 p.m. the following was noted in the B Wing medication room: Two open vials of Tuberculin skin testing serum without a date opened with an inaccurate expiration date of 11/16/18. Five hemorrhoid suppositories loose in the refrigerator without a bag, label, or resident name. Medication refrigerator temperature of 31 degrees F at 12:51 p.m. Medication refrigerator temperature of 34 degrees F at 1:30 p.m. Medication refrigerator temperature of 32 degrees F at 5:45 p.m. During an interview at the time of the observations, Registered Nurse (RN) Employee E13 and the Director of Nursing confirmed that the facility failed to safely store, label and date medications and biologicals. A review of the medication refrigerator temperature logs for July, August, and September 2017, was completed and revealed the following: 7/5/17-temperature of 34 degrees F. 7/6/17-temperature of 32 degrees F. 8/10/17-no temperature recorded. 8/11/17-temperature of 32 degrees F. 8/12/17-temperature of 32 degrees F. 8/14/17-temperature of 32 degrees F. The temperatures recorded from 8/15/17, through 9/30/17, were all recorded as 36 degrees F. During an interview on 10/3/17, at 2:42 p.m. the Nursing Home Administrator confirmed that the facility failed to safely store medications that require refrigeration and that there was no evidence of notification of administration, maintenance or pharmacy regarding refrigerator temperatures that were close to or out of safe storage range. During an observation on 10/2/17, at 1:40 p.m. the following items were noted in the A Wing medication room: A purse was on the counter in the medication room. A cardboard box of blood collection supplies was noted on the floor of the medication room. During an interview on 10/2/17, at 1:40 p.m. RN Employee E1 confirmed that a purse was stored in the medication room and the box of supplies was left on the floor. During an observation on 10/2/17, at 1:50 p.m. a container of skin irritation paste prescribed for Resident R30 and a container of skin irritation ointment prescribed for Resident R6 was observed in the A Wing soiled utility room. During an interview on 10/2/17, at 1:50 p.m. RN Employee E1 confirmed that the biologicals were not stored properly. During an observation on 10/3/17, from 2:15 p.m. to 2:30 p.m. the following unsecured medications were noted on the A Wing nursing station desk, while Licensed Practical Nurse (LPN) Employee E11 worked on a computer with his back to the medications: [REDACTED] A bottle of eye drops for Resident R18. An inhaled breathing treatment solution and artificial tears for Resident R28 Five medication cards containing: blood pressure medication for Resident R25, vitamins for eye health for Resident R26, stomach medication for Resident R27 and stool softener tablets for Resident R29. During an interview on 10/3/17, at 2:30 p.m. LPN Employee E11 confirmed that the medications listed above were not properly stored. 28 Pa. Code: 211.9 (a) (1) (2) (g) (h) (k) Pharmacy Services. Previously cited 11/18/16. 28 Pa. Code : 211.12 (d) (1) (2) (3) (5) Nursing services. Previously cited 11/18/16.

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to accurately assess and provide interventions to prevent the development of a pressure ulcer which resulted in harm for one of two residents reviewed (Resident R3). Findings include: The facility, Pressure Ulcer Protocol policy dated 10/19/15, indicated that the, Braden Scale Tool (assessment tool used to predict pressure sore risk) is filled out on admission and if there is any change of condition to the resident. Refer to standards of care according to risk and stage of pressure ulcer (localized injury to the skin or underlying tissue). Initiate preventive measures. Consult the [MEDICATION NAME][MEDICATION NAME] Nurse (Nurse who specializes in care of skin as it relates to any wound, tissue, and ostomies breakdown) for Stage II (partial thickness loss of dermis (inside layer of skin)) or greater and consult physician for treatment. The quarterly Minimum Data Set Assessment (MDS-a periodic assessment of resident status and care needs) dated 8/15/15, revealed that Resident R3 had an altered mental status. The assessment also revealed that Resident R3 was at risk for pressure ulcer development. In addition, the resident required assistance for transfers and was non-ambulatory. The care plan did not include a plan of care for prevention of pressure ulcers. A review of the Decubitus (tissue breakdown) progress notes dated 8/18/15, 8/25/15, 9/1/15, 9/8/15, 9/15/15, 9/22/15, and 9/29/15, indicated skin intact no open areas. Documentation did not include a plan of care or interventions for Resident R3 who was at risk for pressue ulcer development. A review of the Decubitus progress notes dated 10/23/15, revealed that Resident R3 developed a 3 cm (centimeter) open area to inner left heel. This description was how it was written in the progress note. According to the facility policy, the facility should have consulted the [MEDICATION NAME][MEDICATION NAME] Nurse and the physician for a treatment as soon as the area was found. On 10/27/15, progress notes indicated a 3cm x 7cm open area to the left heel. On 10/28/15 (five days later), Registered Nurse, Employee E1 examined the wound and a physician order [REDACTED]. During an interview on 10/29/15, at 1:40 p.m., the Director of Nursing confirmed that the facility failed to provide interventions, consult the [MEDICATION NAME][MEDICATION NAME] Nurse and physician, and failed to provide treatment resulting in a pressure sore on Resident R3's left heel. Failed to assess (the completion of the Braden scale) and to consult with the [MEDICATION NAME][MEDICATION NAME] Nurse resulting in a delay in treatment. 28 Pa. Code 211.10(a) Resident care policies. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 11/14/14, 10/18/13. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 11/14/14, 10/18/13. 28 Pa. Code 211.12(d)(2) Nursing services.

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide timely skin care interventions which resulted in harm for one of two residents reviewed (Resident R13). Findings include: The facility, Dressing Change-Clean policy dated 10/19/15, indicated that a clean dressing is used to provide an appropriate environment conducive for wound healing. Inform the Infection Control Nurse and the physician as needed regarding untoward observations. The annual Minimum Data Set Assessment (a periodic assessment of resident status and care needs) dated 9/12/15, indicated that Resident R13 had muscle weakness and a history of hip repair, due to a fracture. A nursing note dated 8/11/15, revealed that Resident R13 obtained a skin tear on 8/11/15, to the right, lower extremity, while ambulating with a walker. Resident R13's treatment record did not indicate that the resident received wound care to the area until 8/20/15, (nine days later) after being seen by Physician Employee E10, who ordered Santyl ointment (enzymatic [MEDICATION NAME] agent) and an oral antibiotic due to a wound infection. During an interview on 10/29/15, at 1:40 p.m., the Director of Nursing confirmed that the facility failed to provide timely medical treatment which resulted in harm to Resident R13's right lower extremity. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 11/14/14, 10/18/13. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 11/14/14, 10/18/13. 28 Pa. Code 201.20(a) Staff development. 28 Pa. Code 201.20(b)(c) Staff development. Previously cited 11/14/14. 28 Pa. Code 201.29(d)(j) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 11/14/14, 10/18/13. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 11/14/14, 10/18/13. 28 Pa. Code 211.12(d)(2) Nursing services.