Every finding on record at Kadima Rehabilitation & Nursing at North Strabane

Based on review of facility policy, observations, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information for one of nine residents observed (R1).Findings include:Review of facility policy Confidentiality Policy indicated employees are required, at all times, to comply with HIPAA requirements and other federal and state laws applicable to the confidentiality of personal health information (PHI), and employees must reasonably protect confidential information.Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included depression, and acute respiratory failure (lungs cannot effectively exchange oxygen and carbon dioxide in the blood).Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 1/16/26, indicated the diagnoses are current.Review of a physician order dated 2/22/26, indicated endocrine referral for osteoporosis management.During an observation on 4/2/26, at 9:00 a.m. revealed a stapled packet of paper laying face up on the counter at the nurse's station, in view of residents, family, visitors, and non-medical staff. The packet included Resident R1's demographic information with home address, date of birth , physician name, and diagnoses with Resident R1's pick up time from the facility (10:30 a.m.) and F/U (follow-up) endocrinology (study of the endocrine system - glands that secrete hormones directly into the bloodstream), physician orders as of 4/1/26, and a blank 'Report of Consultation'. Staff were not visible from the nurse's station.During an interview on 4/2/26, at 9:04 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed Resident R1's confidential personal health information should not be accessible at the nurse's station.During an interview on 4/2/26, at 9:30 a.m. the Director of Nursing confirmed the facility failed to maintain the confidentiality of residents' medical information for Resident R1.PA Code 211.5(b) - clinical Records

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to properly secure a treatment cart for one of three carts observed (treatment supply cart).Findings include: Review of facility policy Storage of Medications indicated compartments containing medications are locked when not in use. Trays or carts used to transport such items are not left unattended. During an observation on 4/2/26, at 9:00 a.m. a treatment cart was located outside of resident room [ROOM NUMBER]A, unlocked and unattended. During an interview on 4/2/26, at 9:04 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed the treatment cart should not be left unlocked and unattended. During an interview on 4/2/26, at 9:30 a.m. the Director of Nursing confirmed the facility failed to properly secure a treatment cart. Pa Code: 205.28(c)(3)(4) Nurses' StationPa Code: 211.9(a)(1)()h)(k)(l)(1) Pharmacy ServicesPa Code: 211.12(d)(1)(2)(3)(5) Nursing Services

Based on a review of select facility policy and staff interview, it was determined the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections.Findings include:During an interview on 2/18/26, at 12:08 p.m., the Director of Nursing (DON) stated that the facility just hired the Infection Control Nurse and that the DON is acting as the Infection Control Nurse at this time, as she has the training. The DON confirmed that the facility failed to designate a qualified individual(s) onsite, who is responsible for implementing programs and activities to prevent and control infections.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 201.19(3) Personnel records.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy and procedure, clinical record review, and staff interview, it was determined that the facility failed to offer the COVID-19 vaccine as indicated by the Centers for Disease Control (CDC) for five of five residents reviewed (Residents R6, R18, R21, R23, and R40). Findings include: A review of the facility policy, Covid 19 Vaccination Policy, dated 1/12/23, indicated the facility will comply with all applicable laws and is based on guidance from the Centers for Disease Control and Prevention and local health authorities, as applicable. Immunizations will be offered as indicated. A review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of immunization information revealed that the last COVID-19 immunization was on 11/19/21. There was no evidence that the facility provided vaccine information or offered COVID-19 immunization after 2021. A review of the clinical record indicated Resident R18 was admitted to the facility on [DATE]. Review of immunization information revealed that the last COVID-19 immunization was on 1/20/21. There was no evidence that the facility provided vaccine information or offered COVID-19 immunization after 2021. A review of the clinical record indicated Resident R21 was admitted to the facility on [DATE]. Review of immunization information revealed that the last COVID-19 immunization was on 10/19/21. There was no evidence that the facility provided vaccine information or offered COVID-19 immunization after 2021. A review of the clinical record indicated Resident R23 was admitted to the facility on [DATE]. Review of immunization information revealed that the last COVID-19 immunization was on 10/19/21. There was no evidence that the facility provided vaccine information or offered COVID-19 immunization after 2021. A review of the clinical record indicated Resident R40 was admitted to the facility on [DATE]. Review of immunization information revealed that the last COVID-19 immunization was on 11/9/21. There was no evidence that the facility provided vaccine information or offered COVID-19 immunization after 2021. During an interview on 10/11/24 at 10:30 a.m., the Director of Nursing (DON) confirmed that the facility had no additional information to evidence that Residents R6, R18, R21, R23, and R40 were provided education regarding COVID 19 immunizations, or an immunization to remain up to date with the available COVID-19 vaccines. 28 Pa. Code 211.5(f) Medical records. 28 Pa. Code 211.10(a)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for four of 10 residents (Resident R14, R22, R48, and R57). Review of facility policy Flow of Care dated 2/22/24, indicated the provision targeted care needs shall be documented on Care Tracker/Point of Care/ADL Flow Records (clinical documents). Residents are to have 2 showers a week unless resident states otherwise. Review of the admission record indicated Resident R14 admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/13/24, indicated the diagnoses of Diabetes Mellitus, kidney disease, Schizoaffective disorder, and morbid obesity. Review of Resident R14's Bath/ Shower Task for 30 days Report dated September and October 2024 did not include documentation of showers being provided for seven of seven days( 9/16, 9/17, 9/23, 9/30, 10/1, 10/7, and 10/8). Review of Resident R14's facility provided shower sheets, dated 10/3, indicated shower refusal and 10/7 indicated a bed bath being given, however, had not been documented in Resident R14's clinical record. Review of admission record indicated Resident R22 was admitted to the facility on [DATE], with diagnoses which included irregular heart beat and cancer of the prostate and bladder. Review of Resident R22's Bath/ Shower Task for 30 days Report dated September and October 2024 did not include documentation of showers being provided for seven of seven days( 9/16, 9/17, 9/23, 9/30, 10/1, 10/7, and 10/8). Review of Resident R22's facility provided shower sheets, dated 9/28 indicated shower refusal and 10/2 indicated a shower had been provided. Documentation in the clinical record had not been identified. Review of the clinical record indicated Resident R48 was admitted to the facility on [DATE]. Review of Resident R48's MDS dated [DATE], indicated the diagnoses of high blood pressure, hyperlipidemia (high fats in the blood) and depression. Review of Resident R48's clinical record Documentation Task Report dated September and October 2024 did not include documentation of showers being provided between 9/14/24 through 10/6/24. During an interview on 10/9/24, at 4:00 p.m. the Director of Nursing (DON) provided facility documentation to indicate that Resident R48's showers were documented on paper, CNA Shower Review dated 9/23/24, 9/24/24, and 10/7/24 and confirmed that two of the three showers had not be transferred to the electronic medical. Review of the admission record indicated Resident R57 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], indicated diagnoses of asthma, respiratory failure and heart failure. Review of Resident R57's Bath/Shower Task for September 2024, indicated Resident R57 gets showers on Monday and Thursday. The clinical record did not include documentation of showers being provided on 9/16, 9/19, 9/23, and 9/26/24 as scheduled. During an interview on 10/9/24, at 3:00 p.m. the DON confirmed the above findings and that the facility failed to make certain that medical records on each resident are complete and accurately documented for residents R14, R22, R48, and R57. 28 Pa. Code 211.5(f) Clinical Records. 28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain call bells were in reach for three of eight residents as required (Resident R30, Resident R35, and Resident R36). Findings include: The facility policy Call Light Response dated 2/22/24, indicated a call bell or alternative device will be placed within the reach of each resident while in their room, toilet, or bathing area. Review of Resident R30's clinical record indicated admission to the facility on [DATE]. Review of Resident R30's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/1/24, indicated diagnoses of hypertension (high blood pressure) hyperlipidemia (high fats in the blood) and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). During an interview on 10/8/24, at 10:30 a.m. Resident R30's was laying in his bed, his call light button was on the floor. When Resident R30 was asked what he would do if he needed help, he stated I don't know, I don't know where my call bell is. During an interview on 10/8/24, at 10:45 a.m. Registered Nurse (RN) Employee E1 confirmed the call bell was on the floor and not accessible for Residents R30's use. Review of admission record indicated Resident R35 admitted to the facility on [DATE]. Review of Resident R35's Minimum Data Set (MDS- a periodic assessment of care needs) dated 2/3/24, indicated the diagnoses of hemiplegia of left dominant side (paralysis of left side), following a stroke and depression (mood disorder affecting how one feels, thinks, and handles daily activities). During an interview on 10/8/24, at 10:48 a.m. Resident R35's was laying in her bed, her call light button was on the floor and not accessible. During an interview on 10/8/24, at 11:08 a.m. Graduate Practical Nurse (GPN) Employee E2 confirmed that Resident R35's call bell was not accessible. Review of admission record indicated Resident R36 admitted to the facility on [DATE]. Review of Resident R36's Minimum Data Set (MDS- a periodic assessment of care needs) dated 2/3/24, indicated the diagnoses of hemiparesis following a stroke and hypertension (high blood pressure). During an interview on 10/8/24, at 10:56 a.m. Resident R36's was lying in his bed, his call light button was on the floor and not accessible. During an interview on 10/8/24, at 11:08 a.m. GPN Employee E2 confirmed the call bell was on the floor and not accessible for Residents R36. During an interview on 10/10/24 at 11:20 a.m. Director of Nursing (DON) confirmed the facility failed to make certain call bells were accessible for use for three of eight residents as required. (Resident R30, Resident R35 and Resident R36). 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. 28 Pa Code: 201.29 (I)(o) Resident rights.

Based on review of facility policy, observation, clinical record review and resident and staff interview, it was determined that the facility failed to provide adequate hygienic care for four of seven residents (Resident R15, R25, R38 and R54). Findings include: Review of the facility policy Flow of care dated 2/22/24, indicated that residents are to be provided care as needed on a 24 hour basis to attain and maintain the highest level of functioning. Review of the facility policy Nail Care dated 2/22/24, indicated that resident's fingernails will be cleaned and trimmed as needed or per request. During an observation on 10/9/24, from 8:25 a.m., through 9:18 a.m., the following was observed: Resident R15 was in bed, her fingernails were very long and unclean. She had her feet covered but when asked she showed toenails that were long and had sharp edges and were unclean. Review of Resident R15's shower sheet documentation dated 9/30/24, did not include documentation of whether or not her fingernails needed trimmed. Resident R25 was sleeping with her feet uncovered and her fingernails were long with black substances under them and her toenails were callused, long and soiled. Review of Resident R25's shower sheet documentation dated 9/6/24, identified that Resident R25 fingernails needed trimmed. Resident R38 was in her room, her fingernails were very long and unclean. Resident R38 had no shower sheets found. Resident R54 was observed in his room with long fingernails and he showed his toenails that were long and unclean. Due to his communication disorder, he used yes, no and hand gestures and when asked about nail trimming he said no, no and used his hand as clipper and pointed to toenails. Resident R54 shower sheet documentation dated 9/9/24, indicated that Resident R54 fingernails needed trimmed. During an interview on 10/9/24, at 8:55 a.m., Resident R38 stated that she has not had her fingernails or toenails cut since she has been in the facility. She stated that you cannot get anyone to do that. Resident R54 was observed in his room with long fingernails and he showed his toenails that were long and unclean. Due to his communication disorder, he used yes and no and hand gestures and when asked about nail trimming he said no, no and used his hand as clipper and pointed to toenails and said no, no. During an interview on 10/9/24, at 9:42 a.m., the Director of Nursing (DON) confirmed that the facility failed to make certain that resident finger nails were trimmed and the DON stated that the Social Worker had not had podiatry in since June 2024 and services had not been provided for the four of seven residents identified (Resident R15, R25, R38 and R54) as required. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that a pneumococcal immunization was offered to two of five residents (Resident R18, R40). Findings include: Review of the facility policy Resident Immunizations dated 1/12/23, indicated the facility will offer Pneumovax and Influenza vaccines as indicated. Review of the Centers for Disease Control (CDC) document, Pneumococcal Vaccination: Summary of Who and When to Vaccinate last reviewed 1/24/22, indicated that CDC recommends pneumococcal vaccination for all adults [AGE] years or older, and for adults 19 through [AGE] years old who have certain chronic medical conditions or other risk factors. Review of the Admission Record indicated that Resident R18 was admitted to the facility on [DATE]. Review of Minimum Data Set (MDS-periodic assessment of care needs) dated 6/27/23, included diagnoses of Multiple Sclerosis, paraplegia, and seizure disorder. Section O0300 Pneumococcal Vaccine indicated Resident R18 was not up to date and was offered and declined. There was no evidence in the clinical record that the resident was offered and declined the Pneumococcal Vaccine. Review of the clinical record failed to include documentation of education provided to Resident R18 and/or their representative of the risks and benefits of the pneumonia vaccination. Review of the Admission Record indicated that Resident R40 was admitted to the facility on [DATE]. Review of Minimum Data Set (MDS-periodic assessment of care needs) dated 8/25/22, included diagnoses of Atrial Fibrillation (a heart arrhythmia), paraplegia, and schizophrenia. Section O0300 Pneumococcal Vaccine indicated Resident R18 was not up to date and was offered and declined. There was no evidence in the clinical record that the resident was offered and declined the Pneumococcal Vaccine. Review of the clinical record failed to include documentation of education provided to Resident R40 and/or their representative of the risks and benefits of the pneumonia vaccination. During an interview on 10/11/24, at 10:30 a.m. the Nursing Home Administrator confirmed that the facility failed to make certain that a pneumococcal immunization was offered to Residents R18 and R40. 28 Pa. Code 211.5(f) Clinical records.

Based on a review of vendor invoices, facility financial documents, and interviews with vendors and staff, it was determined that facility failed to pay bills in a timely manner. Findings include: Review of 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection S201.14(g), dated 7/1/23, indicated that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the residents' health and safety are jeopardized. Review of vendor submitted communication dated 12/27/23, indicated that the Ambulance Vendor was no longer providing services to the company, and was owed $29,361.90. During an interview on 3/6/24, at approximately 1:46 p.m., the Nursing Home Administrator confirmed that the facility no longer utilizes the services of the Ambulance Vendor, and provided alternative transportation with another vendor and the use of the facility transport van. Review of the facility provided contractor report on 3/6/24, at approximately 1:44 p.m. revealed a balance of $27,649.37. During an interview on 3/6/24, at approximately 1:46 p.m., the Nursing Home Administrator confirmed that the facility failed to pay bills in a timely manner. 28 Pa. Code: 201.14(g) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1)(2) Management.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for four of seven Residents (Residents R5, R12, R15, and R29). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it's untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of the facility policy Nursing Care of the Diabetic Resident reviewed 1/12/23, indicated the facility will recognize, assist, and document the treatment of complications commonly associated with diabetes. Documentation should reflect the carefully assessed diabetic resident; document interventions to stabilize blood glucose levels and response; document notification to physician of unstable and/or variances from baseline per physician order. Review of the facility policy Notification of Condition Change: Physician reviewed 1/12/23, indicated licensed professional nurses are responsible to provide timely and complete communication to physicians when there is a change in a resident's condition. Document assessment data, attempted or actual correspondence with physician, and physician's response in the medical record. Review of the facility Hypoglycemia Protocol Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and depression. Review of Resident R5's Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 9/13/23, indicated the diagnoses remain current. Review of physician orders dated 7/10/23, indicated to inject Lispro (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) insulin per sliding scale before meals and to notify the doctor if blood glucose was less than 70. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 9/15/23, at 8:43 a.m. CBG was noted to be 62, confirmed at 8:44 a.m. Review of Resident R5's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 1/30/23, indicated blood glucose monitoring as ordered, administer meds per doctor order, monitor for signs and symptoms of low blood sugar, and sliding scale coverage as ordered. Review of a clinical record indicated Resident R12 was admitted to the facility on [DATE], with diagnoses that included diabetes, depression, and hemiparesis (weakness of one side of the body). Review of a physician order dated 8/9/23, indicated to inject Aspart insulin per sliding scale with meals. If blood glucose is greater than 401, give 12 units and call the doctor. Review of Resident R12's eMAR revealed that the resident's CBG's were as follows: On 8/18/23, at 4:16 p.m. CBG was noted to be 417. A review of Resident R12's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, interventions were not documented, blood sugar was not rechecked, and the physician was not notified of abnormal results. A review of Resident R12's care plan dated 8/10/23, indicated to check blood glucose as ordered, call doctor per order. Observe for sign and symptoms of hyperglycemia. Provide insulin coverage as per resident's individual order. Sliding scale coverage as ordered. Review of the clinical record indicated Resident R15 was admitted to the facility on [DATE], with diagnoses that included diabetes, depression, and high blood pressure. Review of Resident R15's MDS dated [DATE], indicated the diagnoses remain current. Review of physician orders dated 1/16/23, indicated to inject Aspart insulin per sliding scale before meals and at bedtime. Further review of a physician's order dated 1/16/23, indicated to give one applicator of Glucose Gel (dextrose gel, a form of sugar used to raise blood glucose levels in hypoglycemia) if blood glucose is less than 70. Recheck blood sugar in 10-15 minutes, may repeat one time. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 6/27/23, at 10:20 p.m. CBG was noted to be 65. On 6/1/23, at 5:09 p.m. CBG was noted to be 59. On 4/23/23, at 4:39 p.m. CBG was noted to be 61. ON 4/14/23, at 9:21 p.m. CBG was noted to be 62. On 4/14/23, at 5:49 p.m. CBG was noted to be 66. On 4/1/23, at 5:30 a.m. CBG was noted to be 53. Glucose gel administered. Review of Resident R15's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 1/17/23, indicated check blood glucose as ordered, call doctor per order. Administer meds per doctor order. Monitor/observe for signs and symptoms of hypoglycemia. Review of the clinical record indicated Resident R29 was readmitted to the facility on with diagnoses that included diabetes, high blood pressure, and anxiety. Review of Resident R29's Minimum Data Set, dated dated dated [DATE], indicated the diagnoses remain current. Review of physician orders dated 2/16/23, indicated to inject Humalog (Lispro) insulin 7 units before meals, and inject Glargine (long-acting insulin that starts to work several hours after injection and keeps working evenly for 24 hours) 12 units once daily. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 9/19/23, at 5:46 a.m. CBG was noted to be 480. On 9/18/23, at 5:35 a.m. CBG was noted to be 409. On 9/4/23, at 6:25 p.m. CBG was noted to be 417. Confirmed at 6:26 p.m. On 9/1/23, at 8:46 p.m. CBG was noted to be 566. On 8/25/23, at 12:13 p.m. CBG was noted to be 422. On 8/21/23, at 4:27 p.m. CBG was noted to be 449. On 8/21/23, at 3:45 p.m. CBG was noted to be 449. On 8/11/12, at 4:59 p.m. CBG was noted to be 420. Review of Resident R29's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 10/31/17, indicated to check blood glucose as ordered, call doctor for abnormal values. Observe/monitor resident for signs and symptoms of hyperglycemia. Provide insulin coverage as per order. During an interview on 10/4/23, at 2:35 p.m. Licensed Practical Nurse (LPN) Employee E1 stated for residents on insulin less than 70 or greater than 400 unless otherwise ordered they would give the prescribed insulin and notify the doctor. For resident's less than 70, a snack or orange juice is given. Documentation is done in the progress notes. During an interview on 10/4/23, at 2:40 p.m. LPN Employee E2 stated for blood glucose levels under 70, they would give glucose or snack, assess the resident, and notify the doctor. If the resident is greater than 400 they would assess the resident, call the doctor, and document in the progress notes. During an interview on 10/4/23, at 2:45 p.m. Registered Nurse (RN) Employee E3 stated they would notify the doctor for blood glucose less than 50-60, and greater than 400 and document in the progress notes. During an interview on 10/4/23, at 2:50 p.m. LPN Employee E4 stated she would notify the doctor of blood glucose less than 70, or greater than 400. She would document in the medical record under the progress notes. She would recheck the blood glucose in 15-30 minutes and document the recheck in progress notes. During an interview on 10/4/23, at 1:55 p.m. LPN Employee E5 stated she would call the doctor for blood glucose less than 70, or greater than 400, recheck in 15 minutes, and document in the progress notes. During an interview on 10/4/23, at 4:00 p.m. LPN Employee E6 stated they would notify the doctor for blood glucose less than 70 or greater than 400. They would recheck the blood glucose in 15-30 minutes and document in the progress notes. During an interview on 10/4/23, at 4:20 p.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition related to blood glucose for Residents R53, R64, R71, and R76. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(d) Resident Rights 28 Pa. Code 211.10 (c)(d) Resident Care policies 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on review of clinical records, financial statements and staff interview it was determined that the facility failed to convey resident funds upon death in a timely manner for one of five closed resident fund accounts (Closed Resident Record CR1). Findings include: Review of the clinical record indicated that Resident CR1 was admitted to the facility on [DATE], for a five day respite stay with possibility of placement under hospice services. The resident had dementia and had been declining at home and had been on hospice. The data under his admission information indicated that he was on hospice and was a private pay. Resident CR1 ceased to breath at the facility on 9/13/22. Review of the facility Resident Ledger for Resident CR1 indicated that his account was billed for 9,100.00 and the Resident family paid 10,950.00 and had a credit owed of 1850.00. During a phone interview on 6/21/23, at 12:38 p.m., the Regional Business Office Manager Employee E1 stated that Resident CR1 was owed the monies and the facility failed to convey the funds of 1850.00 upon his death to his family, as required. 28 Pa. Code: 201.18(e)(1) Management.

Based on review of clinical records reviews and staff interview, it was determined that the facility failed to sure residents maintain basic rights preserved in the Federal and State laws and regulations for five of seven residents (Residents R27, R43, R46, R47, and R49) by having residents sign an Assumption of the Risk and Waiver of Liability Relating to Coronavirus/Covid-19 (Covid-19 waiver). Findings Include: The facility form Assumption of the Risk and Waiver of Liability Relating to Coronavirus/Covid-19 states The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. NORTH STRABANE REHABILITATION AND WELLNESS CENTER (*the Facility*) has put in place preventative measures per state and federal guidelines to reduce or prevent the spread of COVID-19 in the Facility. Due to the nature of COVID-19, however, the Facility cannot guarantee that residents will not become infected with COVID-19. Indeed, admission to the Facility could increase a resident's risk of contracting COVID-19. By signing this agreement, I acknowledge and understand the contagious nature of COVID-19 and voluntarily assume the risk that I or my loved one that I am admitting to the Facility may be exposed to, or infected by, COVID-19. I acknowledge and understand that such exposure or infection may result in personal injury, illness, permanent disability, and death, and I voluntarily assume such risk. I understand that the risk of becoming exposed to or infected by COVID-19 at the Facility may result from the actions, omissions, or negligence of myself and others, including, but not limited to, other residents, Facility employees, contractors, volunteers, or others. I voluntarily agree to assume all of the foregoing risks and hereby accept sole responsibility for any injury to myself or loved one (including, but not limited to, personal injury. disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my loved one may experience or incur in connection with my or my loved one's admission to the Facility (Claims*). I hereby release, covenant not to sue, discharge, and hold harmless the Facility, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Facility, its employees. agents, and representatives, whether a COVID-19 infection occurs before, during, or after admission to the Facility. During an interview on 11/30/22, at 3:11 p.m. Admission Director Employee E2 reported never seeing the form in the two months of his employment with the facility, and that it is not included in the admission packet he had been using during his employment. During an interview on 11/30/22 at 3:29 p.m. the Corporate Compliance Nurse Employee E6 reported that she heard of a form a while back but had never seen one before. Upon inquiry, she confirmed that the form was very broad in limiting residents legal rights, and the form was attempting to absolve the facility of duties and obligations for which they were responsible for. Review of the clinical records revealed Resident R27 was admitted to the facility on [DATE] and signed the Covid-19 waiver, undated by a personal representative. During a telephone interview on 12/1/22, at 2:38 p.m. Resident R27's personal representative reported that he may have signed the waiver, but really don't recall any of the paperwork. Resident R43 was admitted to the facility on [DATE] and signed the Covid-19 waiver form on 6/17/22. During an interview on 12/1/22 at 2:40 p.m. Resident R43 reported that she did not recall signing any waivers, but upon further discussion stated, I hope I didn't sign it. Upon asking if she had known what was involved would she have still signed it, she stated probably not. Review of the clinical records revealed Resident R46 was admitted to the facility on [DATE] and signed the Covid-19 waiver undated. Review of the clinical records revealed Resident R47 was admitted to the facility 5/9/22 and signed the Covid-19 waiver undated. Review of the clinical records revealed Resident R49 was admitted to the facility on [DATE] and signed the Covid-19 waiver dated 5/5/22. During the exit interview by telephone on 12/2/22, the Nursing Home Administrator and Director of Nursing reported that they were unaware the admissions representative was utilizing this form, that they did not feel the form had any legal merit, and agreed that it was an infringement on residents legal rights. 28 Pa Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.18 (b)(2) Management. 28 Pa. Code 201.18(e)(1) Mangement. 28 Pa. Code 201.24(b) Admission policy. 28 Pa. Code 201.24(d) Admission policy.

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for six of eight residents reviewed (Resident R1, R26, R47, R52, R54, and R259). Findings include: A review of the facility policy Advanced Directive last reviewed 7/22/21 and 9/8/22, indicated that information will be provided upon admission of the policies and procedures, or at such time as may be appropriate. A review of the medical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included diabetes, and high blood pressure. A review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 11/14/22, indicated the diagnoses remain current. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R1 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R26 was admitted to the facility on [DATE], with diagnoses that included diabetes, and depression. A review of the MDS dated [DATE], indicated the diagnoses remain current. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R26 was given the opportunity to formulate an Advanced Directive. A review of the medical record indicated Resident R47 was admitted to the facility on [DATE], with diagnoses that included Covid-19, and hypertension (high blood pressure). A review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 10/6/22, indicated the diagnoses remain current. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R47 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R52 was admitted to the facility on [DATE], with diagnoses that included depression, and difficulty swallowing and speaking. A review of the MDS dated [DATE], indicated the diagnoses remain current. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R52 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R54 was admitted to the facility on [DATE], with diagnoses that included depression, anxiety, and high blood pressure. A review of the MDS dated [DATE], indicated the diagnoses remain current. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R54 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R259 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, and depression. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R259 was given the opportunity to formulate an Advanced Directive. During an interview on 11/30/22, at 10:00 a.m. Social Services Employee E3 confirmed that the clinical record did not include documentation that Resident R1, R26, R52, R54, and R259 were afforded the opportunity to formulate Advanced Directives. 28 Pa. Code: 201.29(b)(d)(j) Resident rights.

Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate injuries of unknown origin for three of six residents (Residents R310, R9, R25). Findings include: A review of the facility's policy Abuse Protection dated 9/8/22, previously dated 7/22/21, stated the facility will complete timely and thorough investigations of all reports and allegations of abuse to include injuries of unknown origin. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record revealed that Resident R310 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 11/14/21, included diagnoses of dementia and history of a stroke. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R310's score to be 05, severely impaired. Review of a progress note dated 11/23/21, at 5:23 p.m. indicated NA was doing care on resident and called me into the room to look at her left foot. I noted a bruised area to the top of resident's left foot measuring 5.3 cm x 6.8 cm. Resident was unable to give a description of how it happened. Resident verbally denied pain and no signs or symptoms pain were noted. Review of the facility provided incident report dated 11/23/21, reiterated the progress note. Review of the clinical record revealed that Resident R9 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], and 11/23/22, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking). Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R9's score to be 6, severe impairment for both assessments. Review of a progress note dated 2/1/22, at 4:00 p.m. indicated NA (Nurse Aide) came and got this nurse and stated that resident (R9) had a skin tear on left elbow. Resident unable to give description on how skin tear happened. This nurse assessed resident and cleaned skin tear. Review of the facility provided incident report dated 2/1/22, indicated the skin tear measured 1.5 inches x 1 inch. Review of a progress note dated 7/13/22, at 9:58 a.m. indicated This nurse was called to resident's room (R9) to assess LFA. A large purple bruise with a raised knot like area. Expresses pain when touched. This nurse notified RN to assess. Review of the facility provided incident report dated 7/13/22, indicated the skin tear measured 14 cm (centimeters) x 6 cm, with a small hematoma (pooling of blood) that measured 3 cm x 3 cm. Review of the clinical record revealed that Resident R25 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diagnoses of traumatic brain injury (a disruption in the normal function of the brain)and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R25's score to be 04, severely impaired. Review of a progress note dated 6/1/22, at 11:50 a.m. indicated Resident (R25) acquired new skin tear to left knee. When asked what occurred, resident stated that she was not aware of her having one. Resident is baseline alert to self and sometimes situation. The skin tear was c-shaped measuring 1.7 cm x 0.5 cm. Review of the facility provided incident report dated 6/1/22, indicated a skin tear was identified to Resident R9's left knee and bleeding was present. During an interview on 12/1/22, at 1:15 p.m. the Director of Nursing confirmed that the facility was unable to provide documentation that these of investigations into injuries of unknown origin for three of six residents. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.14 (c)(e) Responsibility of licensee. 28 Pa. Code: 201.18 (e)(1) Management.

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to assess a resident for smoking safety for one of three residents (Resident R54). Findings include: A review of the facility Smoking Policy last reviewed 9/8/22, indicated that upon admission residents who smoke will be reviewed for safety with independence in smoking A review of the clinical record indicated Resident R54 was admitted to the facility on [DATE], with diagnoses that included depression, anxiety, and high blood pressure. A review of the MDS dated [DATE], indicated the diagnoses remain current and the resident is a current tobacco user. A review of the clinical record indicated an admission assessment was completed on 11/12/22, and indicated Resident R54 was a current smoker. A review of the clinical records failed to reveal a smoking assessment was completed for Resident R54. A review of the progress notes dated 11/20/22, revealed medical staff were aware of resident R54 going outside to smoke cigarettes. A review of the care plan revealed smoking interventions added on 11/17/21, that included to monitor for smoking. During an interview on 11/29/22, at 9:20 a.m. the Director of Nursing confirmed the facility failed to complete smoking safety assessments on admission, annually, and quarterly for Resident R54. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.11(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record reviews, and staff interviews, it was determined the facility failed to make certain monthly Medication Regimen Reviews (MRR) were conducted for four of nine residents (Residents R8, R36, R40, and R46). Findings include: Review of facility policy titled Medication Regimen Review last reviewed by the facility on 7/22/21 and 9/8/22, indicated the consultant pharmacist will perform a comprehensive review of each resident's medication regimen at least monthly. A review of the clinical record revealed that Resident R8 was admitted to the facility on [DATE]. The Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/26/22 included diagnoses of lymphedema (swelling in the arm or leg due to a blockage in the lymphatic system), major depression disorder (a mental health disorder characterized by depressed mood or loss of interest in activities), osteoarthritis (a condition when flexible tissue at the end of the bones wears down), and anxiety. There was no documented evidence in Resident R8's clinical record that the required monthly medication reviews were completed by the pharmacist in 1/22, 2/22, 3/22, 4/22, 5/22, 6/22, 7/22, 8/22, 9/22, or 10/22. A review of the clinical record revealed that Resident R36 was admitted to the facility on [DATE]. The Minimum Data Set (MDS- a periodic assessment of care needs) dated 9/28/22 included diagnoses of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), anxiety, depression, and schizophrenia (a mental disorder in which people interpret reality abnormally). There was no documented evidence in Resident 36's clinical record that the required monthly medication reviews were completed by the pharmacist in 12/21, 2/22, 3/22, 4/22, 5/22, 6/22, 7/22, 9/22, or 11/22. A review of the clinical record revealed that Resident R40 was admitted to the facility on [DATE]. The MDS dated [DATE] included diagnoses of high blood pressure, anxiety, depression, and schizophrenia. There was no documented evident in Resident 40/s clinical record that the required monthly medication reviews were completed by the pharmacist in 12/21, 2/22, 4/22, 5/22, 6/22, 7/22, 8/22, 9/22, 10/22, or 11/22. A review of the clinical record revealed that Resident R46 was admitted to the facility on [DATE]. The MDS dated [DATE] included diagnoses of coronary artery disease (condition where the major blood vessels supplying the heart are narrowed), dementia, depression, and malnutrition. There was no documented evidence in Resident 46's clinical record that the required monthly medication reviews were completed by the pharmacist since admission. During an interview on 11/30/22, at 2:05 p.m. the Nursing Home Administrator confirmed the facility failed to make certain that monthly MRRs were conducted for Residents R36, R40 and R46. 28 Pa. 211.9(k) Pharmacy services. 28 Pa. 211.12(c)(d)(3)(5) Nursing services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to date multi-dose over the counter (OTC) medication bottles in one of four medication carts (Avalon Hall Med Cart). Findings include: The facility policy Storage of Medication last reviewed 7/22/21 and 9/8/22, indicated medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. During an observation on 11/29/22, at 8:35 a.m. of the Avalon Hall medication cart revealed the following OTC medications were observed open without a date of opening: One bottle- Vitamin D 10 microgram (mcg) (vitamin supplement) Two bottles - Melatonin 3 milligrams (mg; sleep aid) One bottle - Melatonin 1 mg One bottle - Melatonin 5 mg Two bottles - Antacid tablets (stomach acid relief) Three bottles - Aspirin 81 mg (fever/pain reducer) One bottle - Magnesium oxide 400 mg (supplement) One bottle - Polyethylene Glycol 3350 (laxative) One bottle - Ibuprofen 200 mg (fever/pain reducer) One bottle - Optimum probiotic (supplement) One bottle - Florastor (supplement) One bottle - Aspirin 325 mg One bottle - Famotidine 20 mg (stomach acid reducer) Two bottles - Docusate sodium 200 mg (stool softener) One bottle - Calcium/Vitamin D3 600mg (supplement) One bottle - Diphenhydramine 25 mg (allergy relief) One bottle - Cranberry 425 mg (supplement) One bottle - Folic acid 1 mg (supplement) One bottle - Thiamin/Vitamin B1 100 mg (supplement) One bottle - Ocular vitamin (supplement) One bottle - Guaifenesin 400 mg (cough/mucus relief) One bottle - Mucus relief 600mg One bottle - Omeprazole 10 mg (stomach acid reducer) One bottle - Omeprazole 20 mg Two bottles - Multi-vitamin (supplement) One bottle - Loratadine 10 mg (allergy relief) One bottle - Senna 8.6 mg (stool softener) One bottle - Bisacodyl 5 mg (laxative) One bottle - Vitamin C 250 mg (supplement) One bottle - Vitamin B12 100 mg (supplement) One bottle - Vitamin B12 500 mg One bottle - Iron 325 mg (supplement) During an interview on 11/29/22, at 8:45 a.m. Licensed Practical Nurse Employee E1 confirmed the OTC medication bottles should have been dated when opened as required. During an observation on 11/29/22, at 8:55 a.m. of the 300's Hall medication cart revealed the following OTC medications were observed open without a date of opening: One bottle - Senna 8.6 mg One bottle - Famotidine 20 mg One bottle - Diphenhydramine 50 mg One bottle - Omeprazole 20 mg One bottle - Aspirin 81 mg x3 bottles One bottle - Ibuprofen 200 mg One bottle - Multivitamin Two bottles - Folic acid 1000 mcg x2 Three bottles - Vitamin B12 x3 One bottle - Vitamin C One bottle - Zinc 50 mg One bottle - Vitamin D25 mg One bottle - Calcium D3 600 mg During an interview on 11/29/22, at 9:15 a.m. Licensed Practical Nurse Employee E5 confirmed the OTC medication bottles should have been dated when opened as required. During an interview on 11/30/22, at 10:00 a.m., the Director of Nursing confirmed the OTC medications should have been dated when the bottle was opened. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of the facility's infection control policies and procedures, documents, and staff interview, it was determined the facility failed to implement an antibiotic stewardship program for eleven of twelve months (January, February, March, April, May, June, July, August, September, October, and November 2022). Findings include: Review of the facility policy entitled Antibiotic Stewardship Program dated 9/8/22, previously reviewed 7/22/21, indicated the facility Antibiotic Stewardship Program will track or delegate the tracking of antibiotic days, number of residents on prescribed antibiotics, prescribing practice as they relate to antibiotic usage, antibiotic usage in residents that did not meet the criteria for active infection, types of antibiotics prescribed, overall infection rages, and antibiotic resistant organisms within the facility. Review of the facility provided Infection Control Monthly Data Analysis documentation forms (form that tracks number of infection, , facility tracking maps, and infection ling-listings from January 2022, through November 2022, revealed the following: January 2022: Form was incomplete, map and line list were blank. February 2022: Form was incomplete, map and line list were blank. March 2022: Form was incomplete, no map, and the line list only contained resident's name and antibiotic name. April 2022: Form was incomplete and the line list only contained resident's name and antibiotic name. May 2022: Form was incomplete, map and line list were blank. June 2022: Form was incomplete, map and line list were blank. July 2022: Form was incomplete. August 2022: Form was incomplete. September 2022: Form was incomplete. October 2022: No information was provided. November 2022: No information was provided. During an interview on 12/1/22, at 1:15 p.m. the Director of Nursing confirmed that the facility failed to implement an Antibiotic Stewardship program for eleven of twelve months. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility documentation, clinical records, and staff interview it was determined that the facility failed to provide accurate and timely documentation related to the COVID-19 vaccine for 15 of 56 residents (Resident R4, R10, R13, R18, R24, R32, R38, R43, R45, R47, R48, R52, R53, R54, and R259). During an interview on 11/30/22, at 1:00 p.m. the Director of Nursing confirmed that all vaccination information for residents was maintained in the electronic medical record. Review of the electronic medical record for Residents R4, R10, R13, R18, R24, R32, R38, R43, R45, R47, R48, R52, R53, R54, and R259 failed to include documentation if the COVID-19 vaccine was provided, previously received, or refused. During an interview on 12/1/22, at 11:15 a.m. the Interim Director of Nursing confirmed that no further documentation of COVID-19 vaccine status was available for the above residents. During an interview on 12/1/22, at 11:15 a.m. Nursing Home Administrator confirmed that the facility failed to provide accurate and timely documentation related to the COVID-19 vaccine for 15 of 56 residents. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code: 211.12(d)(1) Nursing services. 28 Pa. Code: 211.12(d)(3) Nursing services.

Based on a review of observations, clinical records, facility employee vaccination data, and staff interviews, it was determined that the facility failed to implement policies and procedures to ensure that all staff were vaccinated for COVID-19 four six of 46 staff members (Therapy Employees E7, E8, E9, E10, E11, and E12). Findings include: The Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality/Quality, Safety and Oversight Group memo (QSO-22-07-ALL) dated 12/28/21, revised 04/05/22, indicated the facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. Regardless of clinical responsibility or resident contact, the policies and procedures must apply to the following facility staff, who provide any care, treatment, or other services for the facility and/or its residents: facility employees, licensed practitioners, students, trainees, and volunteers, and individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement. Review of the facility, COVID 19 Vaccination Policy dated 9/8/22, previously reviewed 7/21/22, indicated this policy will comply with all applicable laws and is based on guidance from the CDC (Centers for Disease Control and Prevention) that all employees are required to receive vaccinations as determined by CMS (the Centers for Medicare and Medicaid Services) unless a reasonable medical or religious accommodation is approved, that the COVID-19 vaccination program applies to all employees, that the facility is responsible for maintaining an accurate record of COVID-19 vaccinations. Review of the facility provided documentation of staff and agency nursing staff COVID-19 vaccination statuses failed to include Therapy Employees E7, E8, E9, E10, E11, and E12. Additionally, medical providers, hospice providers, and other outside vendor staff were not included. During an interview on 12/1/22, at 1:15 p.m. the Interim Director of Nursing confirmed that the facility failed to implement policies and procedures to ensure that all staff were vaccinated for COVID-19. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.14(c) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a) Resident Rights. 28 Pa. Code: 211.12(d)(1) Nursing services. 28 Pa. Code: 211.12(d)(1) Nursing services. 28 Pa. Code: 211.12(d)(2) Nursing services. 28 Pa. Code: 211.12(d)(5) Nursing services.

Based on review of facility policies, documents and clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from neglect by not performing a safe transfer that resulted in a fracture for one of four residents reviewed (Resident R1). Findings include: The facility's policy Abuse Protection dated 2/13/18, defined neglect as the failure to provide goods and services necessary to avoid physical harm, including failure to provide safe services. The facility's policy Mechanical Lift dated 2/13/18, indicated that the lift is to be used by two nursing staff members to perform the procedure. The admission record indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment (MDS - periodic assessment of care needs) dated 5/18/18, indicated that those [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Resident R1's care plans for activities of daily living including transfers and fall prevention, indicated that a Hoyer lift was to be used for transfers. Review of a facility reported incident indicated that on 8/4/18, at 2:00 p.m. Resident R1 complained of left hip and knee pain. An X-ray was obtained which showed an impact [MEDICAL CONDITION] left femur (upper leg) and the resident was transferred to the hospital for treatment. Review of the 8/4/18, Emergency Department (ED) documentation indicated that Pt stated that the aide picked up out of a chair this morning and thought he was the incredible hulk. The ED report indicated that the resident suffered a [MEDICAL CONDITION] left femur (supracondylar fracture) and an immobilizer was applied. Employee witness statements obtained by the Director of Nursing on 8/6/18, revealed that Nurse Aide Employee E1 indicated that he did transfer the resident on 8/4/18, and indicated he used the Hoyer lift. There were 20 witness statements obtained and no other staff person indicated that they had assisted in the transfer of the resident that day. During an interview on 8/14/18, at 9:45 a.m. when asked what happened to her leg Resident R1 indicated, The aide (Nurse Aide, Employee E1) dropped me. During an interview on 8/14/18, at 10:50 a.m. Nurse Aide Employee E2, the nurse aide assigned to Resident R1 on 8/4/18, indicated that Nurse Aide Employee E1 had offered to dress and get Resident R1 up in the chair while she and Nurse Aide Employee E6, were providing care to the resident's roommate. Nurse Aide Employee E2 indicated that there was no Hoyer lift in the room and Nurse Aide Employee E1 did not request assistance to transfer Resident R1 into the chair and had transferred the resident independently. Nurse Aide Employee E2 indicated that on 8/4/18, at 2:00 p.m. she watched Nurse Aide Employee E1 transfer the resident independently into the chair without the use of a lift and Resident R1 complained of pain in the hip and requested pain medication. During an interview on 8/14/18, at 3:00 p.m. Regional Nurse Employees E3 and E4, confirmed that based on the information, Nurse Aide Employee E1 transferred Resident R1 without assistance and without the physician ordered Hoyer lift which resulted in the left femur fracture. 42 CFR 483.12(a)(1) Free From Abuse and Neglect. Previously cited 1/17/18. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 10/18/17, 9/21/17, 10/14/16. 28 Pa. Code 201.18(b)(1) Management. Previously cited 1/17/18, 10/18/17, 9/21/17. 28 Pa. Code 201.18(b)(3) Management. Previously cited 1/17/18, 10/18/17. 28 Pa. Code 201.18(e)(1) Management. Previously cited 10/18/17, 9/21/17. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 1/17/18, 10/18/17, 9/21/17, 10/14/16. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 1/17/18, 10/18/17, 9/21/17, 10/14/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 10/18/17, 9/21/17, 10/14/16.

Based on review of facility policy and clinical records and staff interviews, it was determined that facility staff failed to notify physicians and resident representatives of medications that were not available for 26 of 50 residents (Residents R1 through R26) placing residents in an Immediate Jeopardy situation. Findings include: Review of the Notification of Change in Condition policy, dated 6/1/17, indicated that the nurse was to notify the attending physician and resident representative of any significant change or alteration in treatment, which included medications, and that the nurse document the notification in the medical record. Review of the admission record indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders dated 8/30/17, indicated that Resident R1 was to receive [MEDICATION NAME] (pain reliever) 50 milligram (mg), by mouth every six hours, Nuplazid (antipsychotic used for residents with [MEDICAL CONDITION]) 34 mg, by mouth at bedtime and [MEDICATION NAME] (antidepressant) 10 mg, by mouth at bedtime. Review of the October 2017 Medication Administration Record (MAR) indicated that the [MEDICATION NAME] was not administered to Resident R1 at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. on 10/1/17, and was not administered to the resident at 12:00 a.m. on 10/2/17. The Nuplazid was not administered to Resident R1 at bedtime on 10/1/17 through 10/11/17, and the [MEDICATION NAME] was not administered to the resident at bedtime on 10/11/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R1's physician and resident representative were notified about the unavailability of the medications. Review of the admission record indicated that Resident R2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Annual Minimum Data Set assessment (MDS-periodic assessment of care needs) dated 8/8/17, included an additional [DIAGNOSES REDACTED]. Review of the physician's orders dated 10/7/17, indicated that Resident R2 was to have [MEDICATION NAME] 0.05 mg/24 hour patch ([MEDICATION NAME] hormone replacement therapy), applied weekly on Mondays. Review of the October 2017 MAR indicated that the [MEDICATION NAME] was not applied topically to Resident R2 on 10/9/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R2's physician and resident representative were notified about the unavailability of the medication patch. Review of the admission record indicated that Resident R3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders dated 9/26/17, indicated that Resident R3 was to receive Ampyra (medication used to improve walking in residents with MS) 10 mg, by mouth twice a day and [MEDICATION NAME] (medication used to treat depression) 75 mg, by mouth twice a day. Review of the October 2017 MAR indicated Ampyra was not administered to Resident R3 on 10/2/17, in the evening, on 10/3/17, both morning and evening doses and on 10/4/17, in the morning. The [MEDICATION NAME] was not administered to Resident R3 in the evenings of 10/1/17, 10/2/17 and 10/3/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R3's physician and resident representative were notified about the unavailability of the medications. Review of the admission record indicated that Resident R4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included additional [DIAGNOSES REDACTED]. Review of the physician's orders dated 9/24/17, indicated that Resident R4 was to receive [MEDICATION NAME] (antipsychotic medication) 2.5 mg, by mouth twice a day. Review of the October 2017 MAR indicated that [MEDICATION NAME] was not administered to Resident R4 in the evening of 10/1/17, on 10/2/17 through 10/5/17, and in the mornings of 10/6/17 and 10/7/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R4's physician and resident representative were notified about the unavailability of the medication. Review of the admission record indicated that Resident R5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included additional [DIAGNOSES REDACTED]. Review of the physician's orders dated 8/30/17, indicated that Resident R5 was to receive Atorvastatin (medication used to treat high cholesterol) 20 mg, at bedtime and [MEDICATION NAME] (antidepressant medication) 60 mg, at bedtime. Review of the October 2017 MAR indicated that Atorvastatin was not administered to Resident R5 on 10/2/17, and the [MEDICATION NAME] was not adminstered to the resident on 10/3/17, 10/4/17, and 10/7/17 through 10/11/17. Review of the nurses' notes and physician's orders did not include any documentation that Resident R5's physician and resident representative were notified about the unavailability of the medications. Review of the admission record indicated that Resident R6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders dated 9/19/17, indicated that Resident R6 was to have a [MEDICATION NAME] (local anesthetic to cause numbness) applied to the lower left side of the back, daily in the morning. Review of the October 2017 MAR indicated that that the [MEDICATION NAME] was not applied to Resident R6's back on the mornings of 10/5/17, 10/6/17, 10/9/17 through 10/11/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R6's physician and resident representative were notified about the unavailability of the medication patch. Review of the admission record indicated that Resident R7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician orders dated 8/8/17, indicated that Resident R7 was to receive [MEDICATION NAME] (an antibiotic) 100 mg, by mouth twice a day. Review of the October 2017 MAR indicated that [MEDICATION NAME] was not adminstered to Resident R7 on the evening of 10/5/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R7's physician and resident representative were notified about the unavailability of the medication. Review of the admission record indicated that Resident R8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included additional [DIAGNOSES REDACTED]. Review of the physician orders dated 8/31/17, indicated that Resident R8 was to receive [MEDICATION NAME] (hormone medication) 10 mg, by mouth daily, [MEDICATION NAME] XR (medication to treat moderate to severe dementia) 21 mg, by mouth daily and [MEDICATION NAME] (medication to treat [MEDICAL CONDITION]) 8 mg, by mouth at bedtime. Review of the October 2017 MAR indicated that Resident R8 was not administered the [MEDICATION NAME] XR and [MEDICATION NAME] on 10/8/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R8's physician and resident representative were notified about the unavailability of the medications. Review of the admission record indicated that Resident R9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders dated 10/5/17, indicated that Resident R9 was to receive [MEDICATION NAME] (anti-rejection drug) 500 mg, by mouth twice daily and [MEDICATION NAME] XL (medication to treat high blood pressure) 60 mg, by mouth twice a day. Review of the October 2017 MAR indicated that Resident R9 was not administered the [MEDICATION NAME] on the evenings of 10/5/17 and 10/7/17 and in the mornings of 10/9/17 and 10/12/17. The resident was not administered the [MEDICATION NAME] XL on the evening of 10/11/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R9's physician and resident representative were notified about the unavailability of the medications. Review of the admission record indicated that Resident R10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician orders dated 9/28/17, indicated that Resident R10 was to receive [MEDICATION NAME] (medication to treat [MEDICAL CONDITION]) 60 mg, by mouth daily, [MEDICATION NAME] (medication to treats gout/joint pain) 300 mg, by mouth daily and [MEDICATION NAME] (treats high blood pressure) 2.5 mg, by mouth daily. Review of the October 2017 MAR indicated that Resident R10 was not administered the [MEDICATION NAME] on 10/6 through 10/8/17; the [MEDICATION NAME] on 10/3/17 and 10/4/17; and the [MEDICATION NAME] on 10/3/17, 10/4/17, 10/7/17 and 10/8/17. Review of the nurse notes and physician orders did not include any documentation that Resident R10's physician and resident representative were notified about the unavailability of the medications. Review of the admission record indicated that Resident R11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included additional [DIAGNOSES REDACTED]. Review of the physician's orders dated 9/28/17, indicated that Resident R11 was to receive [MEDICATION NAME] ER (medication to treat high blood pressure) 120 mg, by mouth daily. Review of the October 2017 MAR indicated that Resident R11 was not administered the [MEDICATION NAME] on [DATE]. Review of the nurse's notes and the physician's orders did not include any documentation that Resident R11's physician and resident representative were notified about the unavailability of the medication. Review of the admission record indicated that Resident R12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The significant change MDS dated [DATE], included the same diagnoses. Review of the physician's orders dated 9/2/17, indicated that Resident R12 was to receive [MEDICATION NAME] (medication to prevent blood clots) 75 mg, by mouth daily. Review of the October 2017 MAR indicated that Resident R12 was not administered the [MEDICATION NAME] on 10/7/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R12's physician and resident representative were notified about the unavailability of the medication. Review of the admission record indicated that Resident R13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders dated 9/28/17, indicated that Resident R13 was to receive Namzaric (medication used to treat dementia) 28 mg/10 mg, capsule by mouth daily. Review of the October 2017 MAR indicated that Resident R13 was not administered Namzaric on 10/8/17 through 10/12/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R13's physician and resident representative were notified about the unavailability of the medication. Review of the admission record indicated that Resident R14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included the same diagnoses. Review of the physician's orders dated 9/2/17, indicated that Resident R14 was to receive [MEDICATION NAME] (medication used to treat diabetes) 5 mg, by mouth daily. Review of the October 2017 MAR indicated that Resident R14 was not administered [MEDICATION NAME] on 10/10/17 through 10/12/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R14's physician and resident representative were notified about the unavailability of the medication. Review of the admission record indicated that Resident R15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included the same diagnoses. Review of the physician's orders dated 8/31/17, indicated that Resident R15 was to receive [MEDICATION NAME] XR 14 mg, by mouth daily and [MEDICATION NAME] (medication used to treat diabetes) 625 mg, by mouth three times a day. Review of the October 2017 MAR indicated that Resident R15 was not administered the [MEDICATION NAME] XR on 10/9/17 through 10/11/17, and was not administered two doses of the [MEDICATION NAME] on 10/2/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R15's physician and resident representative were notified about the unavailability of the medications. Review of the admission record indicated that Resident R16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included the same diagnoses. Review of the physician's orders dated 9/28/17, indicated that Resident R16 was to receive [MEDICATION NAME] (anti-anxiety medication) 0.5 mg, by mouth three times a day. Review of the October 2017 MAR indicated that Resident R16 was not administered the [MEDICATION NAME] at 9:00 p.m. on 10/4/17, at 9:00 a.m. on 10/5/17 and 10/6/17, and at 2:00 p.m. on 10/6/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R16's physician and resident representative were notified about the unavailability of the medication. Review of the admission record indicated that Resident R17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual MDS dated [DATE], included additional [DIAGNOSES REDACTED]. Review of the physician's orders dated 8/31/17, indicated that Resident R17 was to receive [MEDICATION NAME] (medication to treat [MEDICAL CONDITION] disorder) 250 mg, by mouth twice a day. Review of the October 2017 MAR indicated that Resident R17 was not administered the [MEDICATION NAME] on the mornings of 10/11/17 and 10/12/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R17's physician and resident representative were notified about the unavailability of the medication. Review of the admission record indicated that Resident R18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included additional [DIAGNOSES REDACTED]. Review of the physician's orders dated 9/14/17, indicated that Resident R18 was to receive Potassium Chloride (an electrolyte supplement) 20 milliequivalent (mEq), by mouth daily and [MEDICATION NAME] (a muscle relaxer) 2 mg, by mouth twice a day. Review of the October 2017 MAR indicated that Resident R18 was not administered Potassium Chloride on 10/6/17 and 10/7/17, and the [MEDICATION NAME] in the mornings of 10/11/17 and 10/12/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R18's physician and resident representative were notified about the unavailability of the medications. Review of the admission record indicated that Resident R19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders dated 9/20/17, indicated that Resident R19 was to receive [MEDICATION NAME] (medication to treat high blood pressure) 20 mg, by mouth daily and [MEDICATION NAME] (an [MEDICATION NAME]) 25 mg, by mouth at bedtime. Review of the October 2017 MAR indicated that Resident R19 was not administered the [MEDICATION NAME] on 10/7/17 and 10/8/17, and the [MEDICATION NAME] on 10/1/17, 10/2/17, 10/4/17, 10/6/17, 10/8/17, 10/9/17 and 10/10/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R19's physician and resident representative were notified about the unavailability of the medications. Review of the admission record indicated that Resident R20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual MDS dated [DATE], included additional [DIAGNOSES REDACTED]. Review of the physician's orders dated 9/12/17, indicated that Resident R20 was to receive [MEDICATION NAME] (antidepressant medication) 100 mg, by mouth at bedtime and Lacrilube ointment (ointment to relieve dry, irritated eyes), in each eye at bedtime. Review of the October 2017 MAR indicated that Resident R20 was not administered the [MEDICATION NAME] and the Lacrilube on 10/5/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R20's physician and resident representative were notified about the unavailability of the medications. Review of the admission record indicated that Resident R21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included an additional [DIAGNOSES REDACTED]. Review of the physician's orders dated 10/7/17, indicated that Resident R21 was to receive [MEDICATION NAME] 75 mg, by mouth daily. Review of the October 2017 MAR indicated that Resident R21 was not administered [MEDICATION NAME] on 10/9/17 through 10/11/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R21's physician and resident representative were notified about the unavailability of the medication. Review of the admission record indicated that Resident R22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders dated 10/7/17, indicated that Resident R22 was to receive [MEDICATION NAME] (a steroid medication) 10 mg, by mouth daily and [MEDICATION NAME] (medication to treat symptoms of [MEDICAL CONDITION]) 10 mg, by mouth daily. Review of the October 2017 MAR indicated that Resident R22 was not administered the [MEDICATION NAME] on 10/9/17 through 10/12/17, and the [MEDICATION NAME] on 10/9/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R22's physician and resident representative were notified about the unavailability of the medications. Review of the admission record indicated that Resident R23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders dated 9/30/17, indicated that Resident R23 was to receive Atorvastatin (cholesterol reducing medication) 10 mg, by mouth at bedtime, Carvedilol (heart medication) 6.25 mg, by mouth twice a day and [MEDICATION NAME] (medication to treat stomach ulcers) 150 mg, by mouth twice a day. Review of the October 2017 MAR indicated that Resident R23 was not administered the Atorvastatin on 10/7/17 and 10/8/17, and the Carvedilol and [MEDICATION NAME] evening doses on 10/7/17 and 10/8/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R23's physician and resident representative were notified about the unavailability of the medications. Review of the admission record indicated that Resident R24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included the same diagnoses. Review of the physician's orders dated 10/5/17, indicated that Resident R24 was to receive [MEDICATION NAME] (medication to treat high cholesterol) 10 mg, by mouth daily. Review of the October 2017 MAR indicated that Resident R24 was not administered the [MEDICATION NAME] on 10/9/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R24's physician and resident representative were notified about the unavailability of the medication. Review of the admission record indicated that Resident R25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included the same diagnoses. Review of physician's orders dated 9/2/17, indicated that Resident R25 was to receive [MEDICATION NAME] (a laxative) 17 grams, in eight ounces of liquid by mouth daily. Review of the October 2017 MAR indicated that Resident R25 was not administered the [MEDICATION NAME] on 10/8/17 through 10/10/17. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R25's physician and resident representative were notified about the unavailability of the medication. During an interview on 10/12/17, at 2:15 p.m. the Director of Nursing (DON) reported that the facility acquired the services of a new pharmacy on 9/25/17, and since then was experiencing many issues regarding prompt delivery of physician ordered medications and confirmed that Residents R1 through R25, did not get all their ordered medications as they were not available because the pharmacy had not delivered them During an interview on 10/12/17, at 3:35 p.m. Licensed Practical Nurse (LPN) Employee E13 confirmed that there were just so many medications unavailable that it was impossible to make phone calls to let the physicians and resident representatives know that the medications were not given because they were unavailable from pharmacy. Review of the admission record indicated that Resident R26 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders dated 10/5/17, indicated that Resident R26 was to receive [MEDICATION NAME] (heart medication) 3.125 mg, by mouth every 12 hours. Review of the October 2017 MAR indicated that Resident R26 was not administered the [MEDICATION NAME] the evening dose on 10/12/17, because it was not available from the pharmacy. Review of the nurses' notes and the physician's orders did not include any documentation that Resident R26's physician and resident representative were notified about the unavailability of the medication. During an interview on 10/13/17, at 8:30 a.m. the DON confirmed that the facility continued to have medications that were not available for many of the residents, that many of the unavailable medications required therapeutic blood levels in order to be effective, were necessary to aide in alleviating discomfort, easing breathing, preventing the development of blood clots and promoting gastric motility, and that by not giving these medications as ordered compromised the residents' overall well-being. The DON also confirmed that the facility staff failed to notify the physicians and resident representatives of Residents R1 through R26 so that the possibility of alternative, available medications, additonal labwork and increased resident monitoring could be initiated. Due to the consistent unavailability of medications for the residents, failure to notify the residents' physicians about the unavailability of some medication and risk of harm, an Immediate Jeopardy was called at the facility on 10/13/17, at 11:25 a.m. Further, the following additional findings confirm the presence of an Immediate Jeopardy. An immediate action plan was requested. An immediate action plan in regard to medication availability was received on 10/13/17 at 4:00 p.m. The plan included that the contracted pharmacy added backup pharmacies to provide additional stat (immediate) runs, nursing staff completed a review of all resident MARs, identified missing medications and provided a list to the pharmacy to fill and process for a stat delivery, nursing staff would have access to a direct pharmacy line to speak directly with a pharmacist, a form was developed for medications removed from the emergency drug kit (EDK) and pharmacy would replenish the EDK on the following day, 10/14/17, and nursing staff were educated in the new process which included the need to notify and document notification of the residents' physicians and resident representatives. Review of the MAR and medication cart availability audit on 10/14/17, identified the following residents that did not have physician prescribed medications available from the pharmacy and were not in the EDK: Resident R26 did not have [MEDICATION NAME] (heart medication) available and the Nuplazid for Resident R1 was still not received. Review of the nurses' notes and the physician's orders did not include any documentation that the physicians and resident representatives of Resident R1 and R26 were notified about the unavailability of the medication. During an interview on 10/14/17, at 2:30 p.m. LPN Employee E5 confirmed that the physicians for Resident R1 and R26 still were not notified about the unavailability of the medications and reported that there were so many medications not available that there just was not enough time to contact the physicians and resident representatives of all the residents involved. During an interview on 10/14/17, at 1:55 p.m. the DON confirmed that multiple physician prescribed medications were not delivered by the pharmacy and that the facility staff failed to notify the physicians and resident representatives of Residents R1 through R26 that these medications were not available and therefore not administered to these residents and verified that the nursing staff were re-educated in the importance of notifying physicians and resident representatives when medications were not available and documenting the notification in the residents' records. On 10/17/17, at 3:48 p.m. the Immediate Jeopardy was lifted following verification that the facility's actions of redeveloping and implementing a new process for obtaining medications from the pharmacy which included, the pharmacy making two deliveries to the facility daily, improving communication among the primary pharmacy, the local backup pharmacies and the facility, providing a list of names of pharmacists and their contact information that was made available to the facility nursing staff on a 24-hour/7 day a week basis and the nurses notifying the physicians and resident representatives and documenting this in the records, was effective. 28 Pa. Code 201.29(a) Resident rights. Previously cited 9/21/17. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 9/21/17, 10/14/16 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 9/21/17. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 9/21/17, 10/14/16.

Based on a review of facility documents, facility policies, and clinical records and staff interviews, it was determined that the facility failed to maintain pharmaceutical services to obtain prescribed medications on a timely basis for 33 of 50 residents (Residents R1 through R33) placing the residents in an Immediate Jeopardy situation. Findings include: A review of the Pharmacy Master Services Agreement, dated 8/8/17, indicated that the facility and pharmacy entered into an agreement in which the contracted pharmacy would provide to the facility pharmacy-related services, prescription drugs and other health care related products and medical devices. The pharmacy would deliver via overnight priority service six day per week and provide services by local pharmacy partners for deliveries that required at other times. The pharmacy would provide on-call services 24 hours per day, 365 day out of the year for emergencies. Emergency drug services included delivery within three days unless there were no supply and then would make arrangements with another pharmacy if the drugs could not be furnished on a prompt and timely basis. The agreement also stipulated that the pharmacy and facility collaborated on the contents of the Emergency Drug Kit (EDK) on an ongoing basis for the purpose of the nurse having access to ordered medications until pharmacy made deliveries. A review of the Medications-Oral Administration policy, dated 9/22/17, indicated that the nurse verified the physician order [REDACTED]. A review of the facility Unavailable Medication policy, dated 9/26/17, indicated that the facility must make every effort to make certain that medications were available to meet the needs of the residents. Review of the admission record indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].) 34 mg, by mouth at bedtime and Celexa (antidepressant medication) 10 mg, by mouth at bedtime. Review of the October 2017 MAR indicated that Tramadol was not administered to Resident R1 at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. on 10/1/17, and was not administered to the resident at 12:00 a.m. on 10/2/17. The Nuplazid was not administered to Resident R1 at bedtime on 10/1/17 through 10/11/17, and the Celexa was not administered to the resident at bedtime on 10/11/17. Review of the admission record indicated that Resident R2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Annual Minimum Data Set assessment (MDS-periodic assessment of care needs) dated 8/8/17, included an additional [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that the Estradiol Transdermal patch was not applied topically to Resident R2 on 10/9/17. Review of the admission record indicated that Resident R3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated Ampyra was not administered to Resident R3 on 10/2/17 in the evening, on 10/3/17 both morning and evening doses, and on 10/4/17 in the morning. The Seroquel was not administered to Resident R3 on the evenings of 10/1/17, 10/2/17 and 10/3/17. Review of the admission record indicated that Resident R4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included additional [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that Zyprexa was not administered to Resident R4 on the evening of 10/1/17, on 10/2/17 through 10/5/17, and in the mornings of 10/6/17 and 10/7/17. Review of the admission record indicated that Resident R5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included additional [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that Atorvastatin was not administered to Resident R5 on 10/2/17, and the Paxil was not administered to the resident on 10/3/17, 10/4/17, and 10/7/17 through 10/11/17. Review of the admission record indicated that Resident R6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that that the Lidocaine patch was not applied to Resident R6's back on the mornings of 10/5/17, 10/6/17, 10/9/17 through 10/11/17. Review of the admission record indicated that Resident R7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that Doxcycline Hyclate was not adminstered to Resident R7 on the evening of 10/5/17. Review of the admission record indicated that Resident R8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included additional [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that Resident R8 was not administered the Provera, Namenda XR and Rozerem on 10/8/17. Review of the admission record indicated that Resident R9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that Resident R9 was not administered the Cellcept on the evenings of 10/5/17 and 10/7/17, and in the mornings of 10/9/17 and 10/12/17. The resident was not administered the Procardia XL on the evening of 10/11/17. Review of the admission record indicated that Resident R10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that Resident R10 was not administered the Armour Thyroid on 10/6 through 10/8/17; the Allopurinol on 10/3/17 and 10/4/17; and the Zebeta on 10/3/17, 10/4/17, 10/7/17 and 10/8/17. Review of the admission record indicated that Resident R11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included additional [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that Resident R11 was not administered the DiltiazemER on [DATE]. Review of the admission record indicated that Resident R12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The significant change MDS dated [DATE], included additional [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that Resident R12 was not administered the Plavix on 10/7/17. Review of the admission record indicated that Resident R13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual MDS dated [DATE], included additional [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that Resident R13 was not administered Namzaric on 10/8/17 through 10/12/17. Review of the admission record indicated that Resident R14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included additional [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that Resident R14 was not administered Tradjenta on 10/10/17 through 10/12/17. Review of the admission record indicated that Resident R15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included the same diagnoses. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that Resident R15 was not administered the Namenda XR on 10/9/17 through 10/11/17, and was not administered two doses of the Welchol on 10/2/17. Review of the admission record indicated that Resident R16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included the same diagnoses. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that Resident R16 was not administered the Ativan at 9:00 p.m. on 10/4/17; at 9:00 a.m. on 10/5/17 and 10/6/17, and at 2:00 p.m. on 10/6/17. Review of the admission record indicated that Resident R17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual MDS dated [DATE], included additional [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that Resident R17 was not administered the Depakote on the mornings of 10/11/17 and 10/12/17. Review of the admission record indicated that Resident R18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included additional [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that Resident R18 was not administered Potassium Chloride on 10/6/17 and 10/7/17, and the Zanaflex in the mornings of 10/11/17 and 10/12/17. Review of the admission record indicated that Resident R19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that Resident R19 was not administered the Lisinopril on 10/7/17 and 10/8/17, and the Benadryl on 10/1/17, 10/2/17, 10/4/17, 10/6/17, 10/8/17, 10/9/17 and 10/10/17. Review of the admission record indicated that Resident R20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual MDS dated [DATE], included additional [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that Resident R20 was not administered the Trazodone or the Lacrilube on 10/5/17. Review of the admission record indicated that Resident R21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included an additional [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that Resident R21 was not administered Plavix on 10/9/17 through 10/11/17. Review of the admission record indicated that Resident R22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that Resident R22 was not administered the Prednisone on 10/9/17 through 10/12/17, and the Singulair on 10/9/17. Review of the admission record indicated that Resident R23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that Resident R23 was not administered the Atorvastatin on 10/7/17 and 10/8/17, and the Carvedilol and Zantac evening doses on 10/7/17 and 10/8/17. Review of the admission record indicated that Resident R24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included the same diagnoses. Review of the physician's orders [REDACTED]. Review of the October 2017 MAR indicated that Resident R24 was not administered the Zetia on 10/9/17. Review of the admission record indicated that Resident R25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], included the same diagnoses. Review of physician's orders [REDACTED]. Review of the October 2017 MAR indicated that Resident R25 was not administered the Miralax on 10/8/17 through 10/10/17. During interviews on 10/12/17, at 12:40 p.m. and at 1:30 p.m. Licensed Practical Nurse (LPN), Employee E2, and Registered Nurse (RN), Employee E1, reported that medications were frequently not available during medication pass, were not available in the EDK and confirmed that many of the residents were not getting their medications as ordered, due to unavailability. During an interview on 10/12/17, at 2:15 p.m. the Director of Nursing (DON) reported that the facility acquired the services of a new pharmacy on 9/25/17, and since then was experiencing many issues regarding prompt delivery of physician ordered medications and confirmed that Residents R1 through R25, did not get all of their ordered medications as they were not available because the pharmacy had not delivered them. During an interview on 10/12/17, at 3:55 p.m. the Nursing Home Administrator (NHA) confirmed being aware of the issues with medication unavailability and that the facility had been working with the corporate staff, but had been unable to get the problems resolved. During an interview on 10/12/17, at 3:35 p.m. LPN, Employee E13, reported that, it's been terrible the past few weeks. I actually phone the pharmacy prior to the start of my shift to see if my residents' medications are going to be here. During an interview on 10/13/17, at 8:30 a.m. the DON confirmed that the facility continued to have medications there were not available for many of the residents, that many of the unavailable medications required therapeutic blood levels in order to be effective, were necessary to aide in alleviating discomfort, easing breathing, preventing the development of blood clots and promoting gastric motility, and that by not giving these medications as ordered compromised the residents' overall well-being. Review of the MAR and medication cart availability audit dated 10/13/17, identified the following additional residents that did not have physician prescribed medications available from the pharmacy and were not in the EDK: Resident R24 did not have Celebrex (anti-inflammatory) available. Resident R27 did not have Keppra (drug used to control seizures) available. Resident R28 did not have Ditropan (drug used to treat an overactive bladder) available. Resident R29 did not have Zyprexa (antipsychotic) available. Resident R30 did not have DuoNeb (combination inhaler that aides in breathing) available. During an interview on 10/13/17, at 8:30 a.m. the DON reported that the Nuplazid for Resident R1 was still not delivered by the pharmacy and that the pharmacy was to deliver the medications for Residents R24, R27, R28, R29 and R30, in their next delivery which should be between 11:00 a.m. and 2:00 p.m. today. Due to the consistent unavailability of medications for the residents and risk of harm, an Immediate Jeopardy was called at the facility on 10/13/17, at 11:25 a.m. Further, the following additional findings confirm the presence of an Immediate Jeopardy. An immediate action plan was requested. An immediate action plan in regard to medication availability was received on 10/13/17 at 4:00 p.m. The plan included: that the contracted pharmacy added backup pharmacies to provide additional stat (immediate) runs; nursing staff completed a review of all resident MARs, identified missing medications and provided a list to the pharmacy to fill and process for a stat delivery; nursing staff would have access to a direct pharmacy line to speak directly with a pharmacist; a form was developed for medications removed from the emergency drug kit (EDK) and pharmacy would replenish the EDK on the following day, 10/14/17; and nursing staff were educated in the new process which included the need to notify and document notification of the residents' physicians and resident representatives. During an interview on 10/13/17, at 4:00 p.m. the DON reported that the medications for Residents R1, R24, R27, R28, R29 and R30 were not included in the pharmacy's delivery and that the facility was working on obtaining them from the local back-up pharmacies. During an interview on 10/13/17, at 7:00 p.m. the DON reported that with the exception of the Nuplazid for Resident R1, the other medications for Residents R24, R27, R28, R29 and R30 were received from the local backup pharmacies. Review of the MAR and medication cart availability audit on 10/14/17, identified the following residents that did not have physician prescribed medications available from the pharmacy and were not in the EDK: Resident R26 did not have Coreg (heart medication) available and the Nuplazid for Resident R1 was still not received. During an interview on 10/14/17, at 8:30 a.m. the DON reported that the facility was informed for the first time last evening that the contracted pharmacy and all their local back-up pharmacies did not have the Nuplazid in stock for Resident R1. Phone calls were then placed to other local pharmacies by the facility, where one pharmacy was found that had it and the Nuplazid would be delivered later today for Resident R1's bedtime dose. The Coreg for Resident R26 was delivered to the facility on [DATE], at 2:00 a.m. by a local back-up pharmacy; however, the resident missed the bedtime dose. During an interview on 10/14/17, at 1:40 p.m. the DON and Corporate Clinical RN Employee E14 confirmed that the pharmacy was still not making certain that physician ordered medications were available for the residents and did not effectively communicate with the facility about Nuplazid for Resident R1 which had been unavailable now for 13 days. Also, the EDK still was not completely replenished by the pharmacy. A revision to the facility's action plan was requested because the current plan that added backup pharmacies to provide additional stat (immediate) runs and replenishment of EDK was not working. A revised immediate action plan was received on 10/14/17, at 2:45 p.m. and included the addition of two deliveries per day to the facility; one by United Parcel Service (UPS) and one by pharmacy courier that was to begin on 10/17/17, and the EDK was to be audited again, a list of any needed medications sent to pharmacy and the medications sent so that EDK would be replenished by 7:00 a.m. on 10/15/17. Review of the MAR and medication cart availability audit dated 10/15/17, identified the following residents that did not have physician prescribed medications delivered from pharmacy; however, these medications were due later in the day and were to be delivered prior to the next dose: Resident R21 did not have Plavix (medication used to prevent blood clots) available for the next dose. Resident R31 did not have Proscar (medication used to treat enlarged prostate), Seroquel (antipsychotic) and Zoloft (antidepressant) available for the next dose. Resident R32 did not have Aricept (medication used to treat dementia) available for the next dose. During an interview on 10/15/17, at 9:00 a.m. the DON reported that the supply of Metformin (medication used to treat diabetes) in the EDK was exhausted and that the facility was expecting replenishment of the EDK and the needed medications for Residents R21, R31 and R32 later today and before the residents' evening doses. During an interview on 10/16/17, at 1:15 p.m. the Nursing Home Administrator (NHA) and Corporate Clinical RN, Employee E14, reported that the unavailable medications that were identified for Residents R21, R31 and R32 were delivered to the facility by a local back-up pharmacy on 10/15/17, at 5:45 p.m. Review of the MAR and medication cart availability audit dated 10/16/17, identified the following residents that did not have physician prescribed medications available: Resident R10 did not have Armour Thyroid (medication used to treat [DIAGNOSES REDACTED]) available for the morning dose. Resident R14 did not have Pristiq (antidepressant medication) available for the morning dose. During an interview on 10/16/17, at 1:30 p.m. the NHA reported that there were still problems with the pharmacy making certain that physician ordered medications were available, that the pharmacy knew that many of the physician ordered medications were going to be taken by the residents on a long-term basis and did not understand why the pharmacy only delivered a few days supply of the medications instead of a larger quantity. During an interview on 10/17/17, at 9:35 a.m. the Medical Director, Employee E9, confirmed that the pharmaceutical needs of the residents were not being met by the pharmacy and reported that, I cannot say that any resident suffered harm; however, agrees the potential is definitely there. Review of the MAR and medication cart availability audit dated 10/17/17, identified the following residents that did not have physician prescribed medications available: Residents R22 and R33 did not have Flomax (medication used to improve urination) available. Resident R11 did not have Cardizem (heart medication) and Lisinopril (medication used to treat high blood pressure) available. Resident R13 did not h ave Levothyroxine (thyroid supplement) and Trileptal (medication used to treat high cholesterol) available. Resident R14 did not have Coreg (heart medication) available. During an interview on 10/17/17, at 10:00 a.m. the DON reported that the nurses were able to obtain the medications for Residents R11, R13, R14, R22 and R33 from the EDK with the exception of the Trileptal for Resident R13 and confirmed that the facility should not be relying so heavily on the EDK and that it was the responsibility of the pharmacy to have the physician ordered medications available. The DON also reported that the pharmacy continued to not be specific with delivery times and there was still concerns with prompt delivery of what medications were needed. A revision to the facility's action plan was requested to include specific time frames for the two times a day delivery. A revised immediate action plan was received on 10/17/17, at 1:00 p.m. and specified that the contracted pharmacy would make their daily delivery in the morning and include all medications identified as being needed by 2:00 p.m. the day before. All orders for new medications and/or needed medications identified from approximately 2:00 p.m. to 9:00 p.m. daily and not available from the backup pharmacies would be delivered by UPS by 10:30 a.m. the next day. During an interview on 10/17/17, at 12:45 p.m. the Pharmacist, Employee E10, reported that the EDK should not be relied on heavily for physician ordered medications, verified that many of the medications that were unavailable for Residents R1 through R33 required therapeutic blood levels in order to be effective, the medications were necessary to aide in alleviating discomfort, easing breathing, preventing the development of blood clots and promoting gastric motility, and that by not giving these medications as ordered compromised the residents' overall well-being. During an interview on 10/17/17, at 2:22 p.m. the NHA and the DON confirmed that the facility failed to maintain pharmaceutical services to obtain prescribed medications on a timely basis for Residents R1 through R33. On 10/17/17, at 3:48 p.m. the Immediate Jeopardy was lifted following verification that the facility's actions of redeveloping and implementing a new process for obtaining medications from the pharmacy which included, the pharmacy making two deliveries to the facility daily, improving communication among the primary pharmacy, the local backup pharmacies and the facility, and providing a list of names of pharmacists and their contact information that was made available to the facility nursing staff on a 24-hour/7 day a week basis and nurses notifying the physicians and resident representatives and documenting this in the records, was effective. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 9/21/17, 10/14/16. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services. Previously cited 10/14/16. 28 Pa. Code 211.9(f)(2)(4)(l)(1)(2) Pharmacy services. 28 Pa. Code 211.10(c) Resident care policies.