Every finding on record at Kendal At Longwood

Based on clinical record review and staff interview it was determined the facility failed to notify the physician of missed medication doses for six of six residents reviewed. (Residents R1, R2, R3, R4, R5, and R6) Findings Include: Review of Resident R1's Medication Administration record (MAR) for September and October 2023 revealed Latanoprost .005% eye drops (medication for the treatment of high pressure in the eye) were not administered as ordered on September 27-30, 2023 and October 4, 2023. Review of Resident R1's clinical record revealed the physician was not notified of the missed does of medication. Review of Resident R2's MAR for September 2023 revealed Senna (stool softener) 8.6 milligrams was not administered on September 1-6 2023, September 8-10 2023, and September 12-19, 2023. Review of Resident R2's clinical record revealed the physician was not notified of the missed does of medication. Review of Resident R3's MAR for September 2023 revealed Lumigan .01% (medication for the treatment of high pressure in the eye) were not administered on September 26, 2023. Review of Resident R3's clinical record revealed the physician was not notified of the missed does of medication. Review of Resident R4's MAR for September 2023 revealed Aldactone 25mg (treats high blood pressure) was not administered on September 2, 2023. Review of Resident R4's clinical record revealed the physician was not notified of the missed does of medication. Review of Resident R5's MAR for September 2023 revealed clonazepam (anti-anxiety) was not administered for one dose the morning of September 18, 2023. Review of Resident R5's clinical record revealed the physician was not notified of the missed does of medication. Review of Resident R6's MAR for September 2023 and October 2023 revealed Pyridium 100mg (used to treat urinary tract infections) was not administered on October 11, 2023, Preservision Supplement (multivitamin) was not administered for two doses on September 26, 2023 and October 19, 2023, and Ocusoft Lid Scrub (eye cleanser) was not administered on September 26, 2023. Review of Resident R6's clinical record revealed the physician was not notified of the missed does of medication. Interview with the Nursing Home Administrator and the Director of Nursing on February 2, 2023 at 11:30 a.m. revealed these medications were not administered due to unavailability from the pharmacy and the physician was not notified per policy when the medications were unable to be administered as ordered. This has been identified as a past non-compliance situation. This was identified by the facility and a plan of correction was developed and put into place including audits of all residents for possible missed notifications to the physician, revisions to the policy and procedure regarding medication errors, education of nursing staff of the policy changes, and continuing audits to ensure compliance. 28 Pa. Code 211.12(5) Nursing Services 28 Pa. Code 201.14(a)(b) Responsibility of licensee

Based on clinical record review and staff interview it was determined the facility failed to provided pharmacy services by not obtaining needed medications for six of six residents reviewed. (Residents R1, R2, R3, R4, R5, and R6) Findings Include: Review of Resident R1's Medication Administration record (MAR) for September and October 2023 revealed Latanoprost .005% eye drops (medication for the treatment of high pressure in the eye) were not administered as ordered on September 27-30, 2023 and October 4, 2023. Review of Resident R2's MAR for September 2023 revealed Senna (stool softener) 8.6 milligrams was not administered on September 1-6 2023, September 8-10 2023, and September 12-19, 2023. Review of Resident R3's MAR for September 2023 revealed Lumigan .01% (medication for the treatment of high pressure in the eye) were not administered on September 26, 2023. Review of Resident R4's MAR for September 2023 revealed Aldactone 25mg (treats high blood pressure) was not administered on September 2, 2023. Review of Resident R5's MAR for September 2023 revealed clonazepam (anti-anxiety) was not administered for one dose the morning of September 18, 2023. Review of Resident R6's MAR for September 2023 and October 2023 revealed Pyridium 100 mg (used to treat urinary tract infections) was not administered on October 11, 2023, Preservision Supplement (multivitamin) was not administered for two doses on September 26, 2023 and October 19, 2023, and Ocusoft Lid Scrub (eye cleanser) was not administered on September 26, 2023. Interview with the Nursing Home Administrator and the Director of Nursing on February 2, 2023 at 11:30 a.m. revealed these medications were not administered due to unavailability from the pharmacy. This has been identified as a past non-compliance situation. This was identified by the facility and a plan of correction was developed and put into place including Audits of all residents for possible missed notifications to the physician, revisions to the policy and procedure regarding medication errors, education of nursing staff of the policy changes, and continuing audits to ensure compliance. 28 Pa. Code 211.9(a)(1) Pharmacy Sevices 28 Pa. Code 211.12(3)(5) Nursing Services 28 Pa. Code 201.14(a)(b) Responsibility of licensee 28 Pa. Code 201.18. Management

Based on a review of the facility's policy, clinical records, facility documentation, and staff interview, it was determined that the facility failed to ensure the correct dose of medication was administered for one of the 14 residents reviewed (Resident 17). Findings include: Review of the facility's policy titled, General Policies for Administration and Documentation of Medications and Treatments last review date January 2017, revealed medications and treatments will be administered by a licensed nurse, in accordance with the Pennsylvania Nursing Code, physician orders and principles of safe medications administration. The Eight Rights will be observed during each medication/treatment administration: Right person; Right drug; Right dose; Right route; Right frequency; Right time; Right reason; and Right documentation. Review of Resident 17's diagnosis includes Epilepsy (neurological disorder marked by a sudden recurrent episode of sensory disturbance, loss of consciousness, or convulsion, associated with abnormal electrical activity in the brain). Review of Resident 17's physician's form dated April 21, 2023, revealed an order for Dilantin (anti-epileptic drug) 30 mg (miligrams) by mouth once a day was given with Dilantin 100 mg to equal 130 mg for Epilepsy. Review of the facility's documentation, Incident Report revealed a medication error incident occurred on September 2, 2023, at 8:00 a.m. Further review of facility documentation including Investigation Review comment section revealed the incident was discovered on September 4, 2023. The resident required physical assistance with breakfast and slept the rest of the day without eating, reported that her/his body was jerking intermittently. The physician was notified, and a STAT (immediate) blood work was ordered. An additional review of the same report revealed that upon reviewing the medication, it was noted that the resident received an extra dose of 30mg of Dilantin on the morning of September 2, 2023. Review of Resident 17's blood work results dated September 5, 2023, revealed a Dilantin level of 23.0 (normal range was 10-20). Review of the physician's progress note dated September 7, 2023, at 9:41 a.m., revealed resident had no reasonable recall, resident received an extra dose of Dilantin over the weekend, had difficulty feeding themself, had tremors, and was less responsive. A/P (Assessment and Plan) revealed a resolved neuro episode, possibly due to an overdose of Dilantin. The above information was discussed with the Director of Nursing on October 5, 2023, at 11:00 a.m. The facility failed to ensure Resident 17 was administered the correct dose of Dilantin. 28 Pa Code 211.10 (d) Resident care policies 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on a review of the clinical record and staff interview, it was determined that the facility failed to ensure that a complete discharge summary was done for one of two residents reviewed (Resident 34). Findings include: Review of Resident 34's clinical record revealed that the resident was admitted to the facility on [DATE]. Review of progress notes revealed that the resident had a planned discharge on October 10, 2022. Further review of the clinical record revealed no documented evidence that the physician completed a discharge summary with a recapitulation of the resident's stay at the facility. Interview with the licensed staff E4 on November 16, 2022, confirmed that the discharge summary was incomplete. 28 Pa Code 211.5 (f) Clinical records

Based upon review of facility policy and procedure, observation, and clinical record review, it was determined the facility failed to ensure residents were free from accidents and hazards for one of eighteen sampled residents (Resident 2). Findings include: Review of facility policy and procedure titled Administration of Oral Medications, revised March 2022, revealed Oral medications will be administered safely and effectively, following Physicians Orders and all regulations. Further review of this policy and procedure revealed Administration - stay with the resident until all medications have been swallowed. The nurse must see the resident swallow the medication before the drug administration can be recorded. Observation of Resident 2's Medication Administration on November 16, 2022, at 9:11 a.m. revealed Licensed Employee E3 prepare Resident 2's medication for administration and leave the medications at resident's chair side without observing Resident 2 take the medications. Interview with Licensed Employee E on November 16, 2022, at 9:12 a.m. revealed Licensed Employee E3 stating we leave her medications in the room as she is a self-administer. We don't spoon feed her. Review of Resident 2's clinical record failed to reveal documented evidence that Resident 2 was assessed to self-administer medication. Interview with the Director of Nursing on November 16, 2022, at 11:00 a.m. revealed that no residents are permitted or assessed for self-administration of medication and further revealed that all staff should remain with all residents until medication administration is complete. The facility failed to ensure residents were free from accidents and hazards. 28 Pa Code 201.14(a) Responsiblity of Licensee 28 Pa Code 201.12(d)(1) Nursing Services 28 Pa Code 201.18(a)(b)(1)(3) Management

Based on observation and staff interview, it was determined that the facility failed to maintain a resident's wheelchair in good repair for one of 16 residents reviewed (Resident 19). Findings include: Review of Resident 19's [DIAGNOSES REDACTED]. Review of Resident 19's Braden Scale (tool used to assess a patient's risk of developing a pressure ulcer) dated (MONTH) 25, (YEAR), identified the resident with a potential problem under the friction/shear section. This section define that the resident move freely or requires minimum assistance. During a move skin probably slides to some extent against a sheets, chair. Observation on (MONTH) 28, 2019 at approximately 11:30 a.m. and on subsequent days of the survey, revealed Resident 19 in a wheelchair with both arms of the wheelchair torn in several places and with rough edges at the tears. Interview with the unit manager, Employee E3, on (MONTH) 31, 2019 at approximately 11:30 a.m. confirmed the condition of the resident's wheelchair and that the wheelchair arms should be replaced. The facility failed to maintain a resident's wheelchair in good repair. 28 PA Code 201.18(b)(1) Management Previously cited 12/28/2017

Based on review of facility policy, review of clinical record, review of facility documentation, and staff interview, it was determined that the facility failed to ensure residents were free of accidents during a transfer via a mechanical lift for one of 16 residents reviewed (Resident 4). Findings include: Review of the facility policy entitled Mechanical Lifts: Sit to Stand Lift, it states in the Procedure: Transfer, section to tighten the cords or attach hooks so that they are in tension and the sling is firm across the resident's back. When the straps are fully extended, but before the resident is clear of the seat, make sure the vest's loops are correctly fastened to the sling bar. Review of Resident 4's nursing notes dated (MONTH) 18, (YEAR) at 10:58 a.m. revealed aide came to nurse crying hysterically stating. resident hit her on lift and it's bleeding. Nurse went in room and saw a 1 cm laceration to right of forehead. Also noticed 2 bruises on both sides of forehead. MD (physician) was notified and nurse receive an order for [REDACTED]. Ice was applied and resident declined Tylenol. Just now at 11:03 a.m. resident denies pain. Review of the facility investigation of Resident 4's incident during transfer via mechanical lift on (MONTH) 18, (YEAR) noted that an interview was conducted with Employee E4 on (MONTH) 10, (YEAR), which revealed the Employee E4 did not have Resident 4 properly strapped on the lift. An interview with the Director of Nursing on (MONTH) 30, 2019 at approximately 1:00 p.m. revealed that Employee E4 did not properly secure the resident prior to the transfer as per the facility policy. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined the facility failed to ensure documentation reflected the resident's status for one out of 16 residents reviewed (Resident 16). Findings include: Review of the facility policy titled, Falls Prevention Management Program, revised (MONTH) (YEAR), indicated to ensure a safe environment for all residents by utilizing a comprehensive falls management program that focuses on person centered fall prevention measures and supports resident independence and dignity. Facility is required to do a Post falls investigation. An investigation of the fall will be completed within 2 to 4 hours post fall by the Falls Investigation Team. The licensed nurse will initiate the 24 Hour Post Fall Assessment Form which includes site of injury, description of the injury, movement of the body part and complaint/assessment of pain. Review of Resident 16's clinical record revealed nursing progress note dated (MONTH) 12, (YEAR) at 9:52 p.m. indicated, CNA (nursing assistant) observed resident sitting on her buttocks with legs extended in front of her, in front of her chair. Resident said she wanted to get something from her closet. CNA notified nurse. Nurse assessed resident. Resident denied hitting head. Resident's left finger slightly swollen, but no c/o (complaint of) pain, moved with no pain. Assisted resident to her chair. Notified daughter and physician. Review of Resident 16's clinical record revealed a physician's progress note dated (MONTH) 8, 2019 at 10:09 p.m. indicated, Pt (patient) being seen for swollen left 4th digit (ring finger). Pt has tenderness at the DIP (distal interphalangeal joint) those between the second (intermediate) and third (distal) phalanges (are bones in the fingers)). Pt did have fall 1-2 weeks ago, area was noticed over weekend and unsure if related to fall. Further review of Resident 16's clinical record revealed there was no documented evidence describing the site of the injury, exact location, movement of the body part and complaint of pain. Interview with the Unit Manager, Employee E3 on (MONTH) 31, 2019 at approximately 1:45 p.m. confirmed there was no documented evidence describing the injury involving the left finger as required 24 hour post fall assessment. The facility failed to maintain complete and accurate medical record for Resident 16. 28 Pa. Code 211.5 (f) Clinical records 28 Pa. Code 211.12 (d)(1) Nursing services Previously cited 12/18/17 28 Pa. Code 211.12 (d)(5) Nursing services

Based on observation, it was determined that the facility failed to ensure that residents were served meals in a dignified manner for one of one dining room observed. Findings include: Observation of dining service on December 21, 2017 at approximately 5:25 p.m. revealed that three residents were noted sitting at corner table. Resident R26 was observed to be completing the main entree and Resident R23 was completing the soup portion of the meal. Resident R9 had no received any portion of the meal. It was not until 5:32 when Resident R9 was served the soup portion of the meal and did not received the main entree until 5:52 p.m. Further observations conducted of dining service on December 21, 2017 at approximately 5:30 p.m. revealed that Resident R21 was not initiating to eat her main entree. Observation of nurse staff who were seated at the table revealed that Resident 21 was prompted once to eat during observation. Observation of Resident R21 at 5:59 p.m. revealed that the resident was escorted out of the dining room without having eaten any portion of her meal and of dessert. Nursing staff was not observed to have provided further prompting to Resident R21 to eat her dinner meal. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management Previously cited on 12/23/15; 01/05/17

Based on clinical record review, facility policy and staff interview, it was determined that the facility failed to obtained pain scales prior to administration of pain medications for two of three residents reviewed. (Resident R44 and R5) Findings include: Review of facility policy entitled Pain Management dated September 2005 with the latest revision date of November 2017 revealed a procedure for assessing and utilizing appropriate pain management tools. Review of policy entitled Pain Management revealed under number 4 of procedure Numerical rating scale assessment tool will be used for residents with no cognitive impairment, or mild to moderate cognitive impairment. The behavior Based Pain Assessment Tool (PAINAD) will be used for residents with severe cognitive impairment. Review of policy Pain Management revealed under number 7 If a resident needs a PRN dose of [MEDICATION NAME] medication, the licensed nurse will document in ID note utilizing the template PRN pain tracker. Review of Resident R44's clinical record included Interdisciplinary progress notes and MARs (Medication Administration Record) for September, October, November, and December 2017 failed to reveal administration of pain scales prior to PRN pain medication. Review of Resident R44's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident R44's November 2017 physician orders [REDACTED].>[MEDICATION NAME] 5 mg -[MEDICATION NAME] 325 mg(milligram) (1 tablet every 4 hours PRN (as needed) for moderate pain (4-6). [MEDICATION NAME] 5 mg -[MEDICATION NAME] 325 mg (2 tablets every 4 hours PRN for pain scale (7-10). Review of Resident R44's September 2017 Medication Administration Record [REDACTED]. There was no evidence that the facility obtained a pain scale prior to administering the PRN (as needed) pain medication. Review of Resident R44's October 2017 MAR failed to reveal documentation of pain scales prior to PRN pain medication administration for [MEDICATION NAME] 5 mg-[MEDICATION NAME] 325 mg (2 tablets) 17 of 37 administrations and 2 of 3 administrations for [MEDICATION NAME] 5 mg-[MEDICATION NAME] 325 mg (1 tablet). Review of Resident R44's November 2017 MAR failed to reveal documentation of pain scales prior to PRN pain medication administration of [MEDICATION NAME] 5 mg-[MEDICATION NAME] 325 mg (2 tablets) 10 of 22 occurrences. Review of Resident R44's December 2017 MAR failed to reveal documentation of pain scale prior to PRN pain medication administration of [MEDICATION NAME] 5 mg-[MEDICATION NAME] 325 mg (2 tablets) 1 of 3 administrations. Further review of Resident R44's September through December 2017 nursing notes revealed no documented evidence that a pain scale was documented prior to the administration of the pain medication for the above above stated administrations. Interview with Licensed nursing staff, Employee E3, on December 28, 2017 at approximately 11:10 a.m. confirmed that the facility began using new electronic documentation for the administration of PRN medications on November 21, 2017. Employee E3 revealed that prior to November 21, 2017 the staff were not documenting pain scales prior to administrations. Interview with Nursing Home Administrator and Director of Nursing on December 28, 2017 at approximately 7:30 p.m. confirmed that pain scales were not administered prior to PRN pain medication administration. Review of Resident R5 electronic clinical record revealed the [DIAGNOSES REDACTED]. Review of Resident R5's quarterly Minimum Data Set (MDS- periodic assessment of resident care needs) assessment dated [DATE] revealed that the resident score 11 out of 15 on the Brief Interview of Mental Status (BIMS- assessment of resident cognitive status) which identified the resident with moderate cognitive impairment. Review of Resident R5's October 2017 physician's orders [REDACTED]. Review of Resident R5 November 2017 physician's orders [REDACTED]. Further review of the November 2017 revealed an order for [REDACTED]. Review of Resident R5 December 2017 physician's orders [REDACTED]. 28 Pa Code 211.10 (c) Resident Care Policy Previously cited on 12/23/15 28 Pa Code 211.12 (d)(1) Nursing Services Previously cited on 12/23/15; 01/05/17

Based on observation, staff interview, review of facility policies and review of manufacturer's guidelines, it was determined that the facility failed to label open medications with open dates and failed to discard expired medications located in one of two medication rooms. (Westmorland nursing unit) Findings include: Review of manufacturer's guidelines for Tubersol (Tuberculin Purified Protein Derivative - used for the detection of [DIAGNOSES REDACTED]) revealed that a vial of Tubersol which has been entered and in use for 30 days should be discarded. Review of facility policy titled Medication Storage, revised February 2016, revealed that multi-dose containers/vials are labeled with a date upon initial opening. Observation of the medication room refrigerator located on the Westmorland nursing unit on January 3, 2017 at approximately 6:40 a.m. revealed one open vial of Tubersol with an open date of November 18, 2016 and one open vial of Tubersol with no open date indicated on the box or vial. Observation of the second medication room refrigerator on the Westmorland nursing unit on January 3, 2017 at approximately 6:50 a.m. revealed one open vial of Tubersol with an open date on the label of November 18, 2016; one open vial of Influenza vaccine with no open date indicated on the box and/or label and one open vial of Lantus Insulin (medication used to treat high blood sugar levels) with no open date indicated on the vial and/or box. The above information was conveyed to the Director of Nursing and Nursing Home Administrator on January 3, 2017 at approximately 12:00 p.m. The facility failed to label open medications with open dates and failed to discard expired medications 28 Pa. Code 211.9(a)(1) Pharmacy Services 28 Pa. Code 211.12(c)(d)(1)(5) Previously cited 12/23/15

Based on review of the clinical record and staff interview, it was determined that the facility failed to notify the physician of a significant change in a resident's condition for one out of 11 residents reviewed. (Resident B13) Findings include: A review of the [DIAGNOSES REDACTED]. Review of the current physician orders [REDACTED]. Review of the vital sign section of the clinical record revealed that a recording of the resident's blood pressure as 231/110 on January 1, 2017 at 10:47 p.m. The reading was recorded in red which indicated by the legend on the page to be a panic value (a value requiring immediate attention). Review of the interdisciplinary notes failed to reveal any note by the nurse regarding the high blood pressure that was obtained. There was no recheck of the blood pressure or further monitoring on subsequent shifts. There was no documentation that the physician was notified of the resident's high blood pressure to obtain further directions for care. Interview with the Nursing Home Administrator and the Director of Nursing on January 4, 2017 revealed that their investigation revealed that the nurse on duty on January 1, 2017 was not informed of the high reading by the nursing assistant Employee E5 who took and recorded the blood pressure. The facility failed to notify the physician of a significant change in a resident's condition to obtain directions for monitoring and treatment. 28 Pa. Code 211.12(d)(1) Nursing Services Previously cited 12/23/15

Based on observation and review of facility policy, it was determined that the facility failed to ensure that a medication cart remained locked on one of two nursing units. (Westmorland) Findings include: Review of facility policy titled Medication Storage, revised February, 2016 revealed that all medications and sharps are maintained in a locked room, cabinet, refrigerator or cart, unless directly attended by authorized personnel. Observation on January 3, 2017 at approximately 5:55 a.m. of the Westmorland nursing unit medication cart revealed that the medication cart was unlocked and no authorized personnel were in attendance to maintain the safety of the residents and the medications located within the medication cart. The above mentioned observation was reported to the Nursing Home Administrator on January 3, 2017 at approximately 12:00 p.m. The facility failed to ensure that the medication in the Westmorland nursing unit was locked to prevent accidents. 28 Pa. Code 201.18(b)(1) Management Previously cited 12/23/15 28 Pa. Code 211.10(d) Resident Care Policies Previously cited 12/23/15 28 Pa. Code 211.12(d)(1) Nursing Services Previously cited 12/23/15

Based on observation and staff interview, it was determined that the facility failed to use proper infection control techniques when feeding residents during meals in one of two dining rooms observed. (Westmorland unit dining room) Findings Include: In reviewing the facility's policy of Handwashing dated February 2016, hands must be washed in the following circumstances: before and after any direct resident contact and between residents,before serving food and before and after assisting a resident with meals. Observations conducted on the Westmorland unit dining room on January 4, 2017 at approximately 12:30 p.m. during lunch, non licensed nursing staff, Employee E1 was observed feeding Resident C13 who was seated to her right. On the left side of non licensed nursing staff, Employee E1 was Resident A9. Employee E1 would turn to Resident C13 give her some of her meal and then turn to Resident A9 and feed Resident A9 some of her meal. This consisted of using utensils, as well as offering sips of beverage, and wiping the residents mouth with a napkin. In addition, non licensed nursing staff, Employee E1 was observed during the time of feeding these two residents' adjusting Resident C13's clothing protector and touching Resident A9's hair. On January 4, 2017 during the same observation, non licensed nursing staff, Employee E2 was observed at another table assisting Residents D9 and Resident A11 with their lunch. Non licensed nursing staff, Employee E2 was seated in between these two residents and during the course of the meal would turn to Resident D9 and assist with feeding and then turn to Resident A11 and assist with his meal, alternating back and forth. This consisted of using utensils, offering of beverage and wiping the residents mouth with a napkin. It was noted that during the course of lunch neither non licensed nursing staff, Employee E1 nor Employee E2 washed their hands when feeding their respective residents . Observations conducted on January 5, 2017 at approximately 12:40 p.m. in the dining room during lunch, non licensed nursing staff, Employee E3 was sitting in between Resident A11 and Resident D9 at a table and assisting both residents with their lunch. Non licensed nursing staff, Employee E3 would alternate between giving some food to Resident A11 and then Resident D9. At one point Resident D9 needed his clothing protector changed due to excessive spillage and non licensed nursing staff, Employee E3 did that, but at no time during meal non licensed nursing staff, Employee E3 washed her hands. Seated at another table was non licensed nursing staff, Employee E4 who was assisting Resident C13 and Resident B2. Non licensed nursing staff, Employee E4 would alternate with assisting both Resident C14 and Resident B2 with eating their meal. Non licensed nursing staff, Employee E4 would offer food/beverage to Resident C14 then turn to Resident B2 and give some food to that resident. In addition, non licensed nursing staff, Employee E4 was noted to assist Resident B2 with holding a straw by her mouth while drinking then turn to Resident C13 and wipe mouth with a napkin. At no time during the observation non licensed nursing staff, Employee E4 noted to have washed her hands in between feeding both of these residents. During two meal observations it was noted that four non licensed nursing staff, employees failed to use proper infection control techniques while feeding residents. 28 Pa. Code 211.10(d) Resident Care Policies Previously cited 12/23/15 28 Pa. Code 211.12(d)(1) Nursing Services Previously cited 12/23/15

Based on a review of the clinical record, facility documentation and staff interviews, it was determined that the facility failed to accurately assess, timely notify the physician and obtain a physician's orders [REDACTED].) Findings include: Review of Resident D2's current [DIAGNOSES REDACTED]. in decreased body metabolism). Review of the quarterly Minimum Data Set (MDS-a periodic assessment completed to identify care needs) assessment completed on September 2, 2015, identified the resident as having moderately impaired cognition and limited assistance of one staff person for bed mobility and transfers. The resident was identified with limited range of motion to the upper and lower extremities on one side of the body. Review of Resident D2's nurses' progress notes dated November 7, 2015 at 11:12 a.m., revealed that the Licensed Practical Nurse, Employee E5, was called to Resident D2's room by her son and told that they had an accident with coffee. The Licensed Practical Nurse, Employee E5, went to assess resident for possible injury and to change resident's clothes. Upon removing the resident's shirt, the resident's right upper arm was noted with [DIAGNOSES REDACTED] (redness of the skin) and the resident was complaining of pain. Further review of the nurses' progress notes indicated that, the area of [DIAGNOSES REDACTED] measured approximately 5 centimeters by 5 centimeters. Supervisor was notified and will notify physician. The son's dog jumped up on the resident as she was drinking coffee and the coffee spilled onto the right arm and the right flank (part of the abdomen) areas. Further review of the resident's clinical record revealed no documented evidence that the burn that was sustained by the resident, was assessed or described by the supervisor until November 9, 2015, (two days after the incident) when the wound nurse assessed and measured the burns. There was no documented evidence that the supervisor notified the physician of the incident until a physician's progress note dated November 10, 2015, (three days after the incident ) revealed that Resident D2 had been seen by the wound nurse for [MEDICAL CONDITION] the right arm and right flank areas, which the physician confirmed were first [MEDICAL CONDITION](cause minimal skin damage. Also called superficial burns because they affect the outermost layer of skin) and second [MEDICAL CONDITION](damage extends beyond the top layer of skin. This extensive damage causes the skin to blister and become extremely red and sore). Review of the facility's investigation report dated November 7, 2015 at 10:30 a.m., described Resident D2's right upper arm with an area of [DIAGNOSES REDACTED] approximately 5 centimeters by 5 centimeters. The resident had complained of pain. The action taken at the time of the incident revealed that the Licensed Practical Nurse, Employee E5, had applied toothpaste to the affected area and wrapped with gauze kling (a bandage that stretches and conforms to the body shape and clings to itself as it is wrapped). There was no documented evidence that the nursing supervisor notified the physician of the incident on November 7, 2015. Review of physician's progress note revealed that it was not until November 10, 2015, (three days later) when it was documented by the physician that the resident sustained [REDACTED]. Also called superficial burns because they affect the outermost layer of skin) and second [MEDICAL CONDITION](damage extends beyond the top layer of skin) to the right arm and right flank from hot coffee. Review of Resident D2's Treatment Administration Record (TAR) for November 2015, revealed that there was no documented evidence that on November 7, 2015, a treatment was ordered by the physician for the burn to Resident D2's right upper outer arm. Further review of the TAR revealed that on November 9, 2015, (two days later after the incident ) a treatment was administered by a Licensed Practical Nurse to the resident's left, upper, outer arm burn for the next two days. There was no documented evidence that the resident sustained [REDACTED]. The investigation report dated November 7, 2015, revealed that the resident sustained [REDACTED]. Review of the November 2015 Treatment Administration Record confirmed that it was not until November 11, 2015, (four days after the incident) that a treatment was ordered and administered by a Licensed Nurse to the resident's burn on the right upper, outer arm. Review of the physician's orders [REDACTED]. Review of the Wound Nurse's progress note dated November 16, 2015, revealed open second degree burn on the right upper arm. Measured 8 centimeters x 7 centimeters x 0.1 centimeters. Wound bed is extremely [DIAGNOSES REDACTED] and surrounding skin is [MEDICAL CONDITION]. The skin was warm to touch and had copious (large amount) amounts of serous (bloody tinge color fluid) drainage. The resident stated, That one hurts. Review of physician's progress note dated November 17, 2015, indicated that Resident D2, has been seen by the wound nurse. Resident's right arm appeared to be more reddened and there was concern of [MEDICAL CONDITION] (inflammation of the skin) developing. Further review of the physician's progress note, revealed an examination completed by the physician which indicated, a second degree burn on the right arm, was developing [MEDICAL CONDITION] and a plan to start Resident D2 on Keflex (an antibiotic medication) 500 milligrams three times a day, for seven days. Review of November 2015, physician's orders [REDACTED]. Review of the Wound Nurse's progress note dated December 21, 2015, revealed that the open second degree burn on the right upper arm, measured 6 centimeters x 1.5 centimeters x 0.1 centimeters and the wound bed was described with some overgranulation ('over grows' beyond the surface of the wound) tissue. There was a moderate amount of serous drainage and the surrounding skin was dry and intact. Interview with the Interim Director of Nursing on December 23, 2015 at 9:45 a.m., confirmed there was no documented evidence relating to [MEDICAL CONDITION] the right upper arm, that the physician was notified or that a physician's orders [REDACTED]. Interview with the Wound Nurse, Employee E4, on December 23, 2015 at 10:30 a.m., revealed that she did not assess, measure or recommend treatment to Resident D2'[MEDICAL CONDITION] Monday, November 9, 2015, after she was made aware of [MEDICAL CONDITION] the spilled coffee. The facility failed to timely assess, notify the resident's physician and obtain an appropriate treatment to Resident D2 who sustained a second degree burn on the right upper arm which resulted in actual harm to Resident D2. 42 CFR 483.25 Provide Care/Services for Highest Well Being. Previously cited 12/23/13 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.5(f) Clinical records. Previously cited 12/23/13 28 Pa. Code 211.5(h) Clinical records. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited 12/23/13, 01/02/15 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 01/02/15

Based on review of the clinical record and interviews with the staff, it was determined that the facility failed to implement interventions to prevent the development of pressure ulcers for two of 12 residents reviewed (Residents B6 and CL3), resulting in harm. Findings include: Review of Resident B6's nursing progress note dated July 28, 2015, revealed that the resident had been readmitted from the hospital at 6:00 p.m., following an admission for a syncopal-bradycardic event with [MEDICAL CONDITION] ([MEDICAL CONDITION] episode with slow heartbeat) requiring the placement of a cardiac pacemaker (a surgically implanted electronic device to stimulate the heartbeat) during the hospital stay. Review of the admission assessment completed July 28, 2015 at 9:00 p.m., revealed that Resident B6's heels were noted to be intact and there was no identification of redness or sponginess. Review of the progress notes dated July 29, 2015 at 10:00 p.m., revealed that the Licensed Practical Nurse, documented that the resident's left ankle and foot exhibited [MEDICAL CONDITION] (swelling). Review of the resident's physician's progress notes dated August 3, 2015, confirmed that the resident was hospitalized due to a syncopal ([MEDICAL CONDITION]) event, and had a permanent pacemaker placed. The resident was treated at the hospital for mild [MEDICAL CONDITION] and was also receiving [MEDICATION NAME] (respiratory treaments) and the antibiotic medication [MEDICATION NAME] for cough, wheezeing with purulen phlegm. Review of the resident's significant change Minimum data Set (MDS-a periodic assessment completed to identify care needs) assessment dated [DATE], identified the resident at risk for pressure ulcer (damage to the skin or underlying structures as a result of tissue compression and inadequate perfusion usually over a bony prominence) development. This assessment also indicated that the resident required the extensive assistance of two persons for moving in bed and transfers from one surface to another. The resident's Brief Interview for Mental Status (BIMS-reasoning/problem solving status) indicated a score of 15 which identified the resident as cognitively intact and would be able to respond to care teaching. Review of the nursing notes dated August 7, 2015, (10 days after re-admission to the facility) at approximately 3:30 p.m., revealed that the nursing assistant reported a purple area on the left heel, while assisting the resident with a shower. This area was identified as a deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) measuring 6.5 centimeters x 5 centimeters, with the skin peeling around the site. The nursing notes further indicated that skin prep (a topical [MEDICATION NAME] antiseptic) was applied to the wound. Review of the facility documentation, titled, Investigation of Skin Injuries dated August 7, 2015, revealed that the two previous shifts (11-7 shift and 3-11 shift) did not identify or note the resident's deep tissue injury to the left heel. Employee E2, the Registered Nurse Manager/Acting Director of Nursing (DON), documented on August 10, 2015, that an interview with the resident, revealed that he thought his heel was rubbing on the bed and Employee E2 documented that the most probable cause of the wound was pressure. Review of the Wound Nurse, Employee E4's, documentation dated August 10, 2015, (three days later from the date the pressure ulcer wound was first identified) confirmed a deep tissue injury on the resident's left heel which measured 5.5 centimeters x 6 centimeters with yellowish purple fluid within firm intact skin. The nursing note dated August 24, 2015, revealed that the deep tissue injury heel wound measured 5.5 centimeters x 6 centimeters, and was filled with yellowish purple fluid and with a newly identified open area at the base of the heel measuring 2 centimeters x 1 centimeters x 0.1 centimeters with a moderate amount of serous (bloody tingue color fluid) drainage. Review of the resident's care plan identified the use of a pressure relief mattress. The intervention of a special air mattress was not put in place until after the resident's left heel deep tissue injury was identified. There was no evidence that the resident's care plan included interventions prevent the development of a pressure ulcer on the resident's heel. An interview with the Director of Nursing on December 23, 2015 at approximately 1:00 p.m., confirmed that although these wounds can develop rapidly, this wound was not identified at an earlier stage and pressure relief measures initiated. The facility failed to put pressure relief interventions in place for Resident B6 who was readmitted to the facility after a pacemaker insertion and was being treated for [REDACTED]. Review of Resident CL3's [DIAGNOSES REDACTED]. cancer. Resident CL3 had been admitted to the facility on [DATE], after a fall at the dentist where she sustained a right pubic ramus fracture (part of the pelvis) and a right shoulder contusion (bruise). The admission MDS assessment dated [DATE], revealed that the resident was at risk for pressure ulcer development. This assessment also indicated that the resident required the extensive assistance of two persons for moving in bed and for transfers. The resident's Brief Interview for Mental Status indicated a score of 15 which identified the resident as cognitively intact. Review of Resident CL3's nursing notes dated October 3, 2015, revealed that a new 3 centimeters x 3 centimeters blister was noted on the resident's right inner heel. The notes stated, Blister is surrounded by a reddened area. Skin prep applied to blister. Medical doctor was notified. Review of the wound nurse's documentation dated October 5, 2015, confirmed an intact blister on the inner aspect of the right heel, described as a Stage II (ulcer involving loss of the top layers of the skin), measuring 3 centimeters x 2 centimeters and the fluid inside the blister appeared to be serous (water fluid that moistens membranes). The documentation indicated that the wound appears to be caused by shearing (frictional force between surfaces) since the resident does not appear to move around much, except to slide herself up in bed slightly. Is status [REDACTED]. Review of the resident's care plan identified the use of a pressure relief mattress. An intervention to float heels (elevate to releave pressure) when in bed, using pillows for positioning, was not initiated until October 16, 2015, 13 days after the right heel blister was identified. Further review of the resident's care plan revealed that Resident CL3 stated, that when in bed she would rest her foot on top of the other foot at night. Interview with the Interim Director of Nursing on December 23, 2015 at approximately 1:15 p.m., confirmed that the intervention on the resident's care plan of floating the resident's heels was not implemented prior to the development of the right heel blister. 28. Pa. Code 211.5(f) Clinical records. Previously cited 12/23/13 28 Pa. Code 211.10(d) Resident care policies. Previously cited 12/23/13 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 12/23/13, 01/02/15 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 12/23/13

Based on observations and staff interview, it was determined that the facility failed to properly contain garbage in the main kitchen. Findings include: Review of the Food and Drug Administration Food Code 2013 Section 5-501.113 indicates that receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered inside the food establishment if the receptacles and units contain food residue and are not in continuous use. Observations during the initial tour of the main kitchen on December 21, 2015 at approximately 12:55 p.m., in the presence of the facility's Food Service Director, Employee E3, revealed two trash cans containing food residue that were not in use. An additional observation on December 23, 2015 at 10:45 a.m., revealed four trash cans that were observed uncovered containing food residue. Interview with Employee E3 on December 21, 2015, during the initial tour, revealed that it is facility protocol not to use lids on the trash cans. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management.

Based on review of Pennsylvania Code, Title 49, Professional and Vocational Standards, Chapter 21, State Board of Nursing, clinical record review and staff interviews, it was determined that the facility failed to meet professional standards of quality, regarding assessment, notification to the physician and obtaining an order for [REDACTED]. Findings include: The Pennsylvania Code, dated April 6, 2013, Title 49 Professional and Vocational Standards, Chapter 21.145 (a) states, the LPN (licensed practical nurse) is prepared to function as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. Chapter 21.145 (a)(1) further states, an LPN shall communicate with a licensed professional nurse and the patient's health care team members to seek guidance when: (i) The patient's care needs exceed the licensed practical nursing scope of practice. (iii) The patient's condition deteriorates or there is a significant change in condition, the patient is not responding to therapy, the patient becomes unstable or the patient needs immediate assistance. Chapter 21.11 (a) states, the registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of the following functions: (4) carries out nursing care actions which promote, maintain and restore the well-being of individuals and (6) evaluates the effectiveness of the quality of nursing care provided. (b) The registered nurse is fully responsible for all actions as a licensed nurse and accountable to clients for the quality of care delivered. Review of Resident D2's nursing note dated November 7, 2015 at 11:12 a.m., revealed that the Licensed Practical Nurse, Employee E5, was called to Resident D2's room by her son and told that they had an accident with coffee. The Licensed Practical Nurse, Employee E5, went to assess resident for possible injury and to change resident's clothes. Upon removing resident's shirt, resident's right upper arm with [DIAGNOSES REDACTED] (redness of the skin) noted and resident complaining of pain. Area of [DIAGNOSES REDACTED] was approximately 5 centimeters x 5 centimeters. Supervisor was notified and will notify physician. The son's dog jumped up on the resident as she was drinking coffee and the coffee spilled onto the right arm and right flank (part of the abdomen) areas. Further review of the clinical record revealed no additional documented evidence that the burn was assessed or described by the supervisor until November 9, 2015, (two days later) when the wound nurse assessed and measured the burns. There was no documented evidence that the supervisor notified the physician of the incident until a physician's progress note dated November 10, 2015, (three days later) revealed that Resident D2 had been seen by the wound nurse for [MEDICAL CONDITION] the right arm and right flank areas, which the physician confirmed were first [MEDICAL CONDITION](cause minimal skin damage. Also called superficial burns because they affect the outermost layer of skin) and second [MEDICAL CONDITION](damage extends beyond the top layer of skin. This extensive damage causes the skin to blister and become extremely red and sore). Review of the facility's investigation report into the burn incident sustained by the resident dated November 7, 2015 at 10:30 a.m., described Resident D2's right upper arm with an area of [DIAGNOSES REDACTED] approximately 5 centimeters by 5 centimeters. The resident had complained of pain. The action taken at the time of the accident revealed that the Licensed Practical Nurse had applied toothpaste to the affected area and wrapped with gauze kling (a bandage that stretches and conforms to the body shape and clings to itself as it is wrapped). Interview with the Nursing Home Administrator on December 22, 2015 at approximately 11:30 a.m., revealed that upon further questioning of the Licensed Practical Nurse, Employee E5, on December 22, 2015, indicated that she was instructed by her supervisor to apply [MEDICATION NAME] (a topical antibiotic cream used to treat or prevent infection of an area of burned skin) to the burn, but if not available, use toothpaste. The facilty failed to notify the physician on November 7, 2015, after the incident to obtain a treatment order to the resident's burn on the right arm and right flank burn areas. The facility failed to provide appropriate treatment to a resident with first and second [MEDICAL CONDITION] delayed treatment to promote healing. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 12/23/13, 01/02/15

Based on review of facility policy and observations, it was determined that the facility failed to ensure that a towel warmer was unplugged when not in use on one out of three bathing suites and failed to ensure that the safety of disinfectant solutions stored in a utility room on one out of one nursing units. Findings include: Review of facility policy, Blanket/Towel Warming Cabinet Policy revised March 2013, revealed that the appliance should be kept locked and unplugged when not in use. Observations during an initial environmental tour on December 21, 2015 at approximately 1:25 p.m., revealed a towel warmer in the bathing suite next to room 405 that was plugged in and unsecured. The temperature reading on the towel warmer was 180 degrees Fahrenheit. Additional observations on December 22, 2015 at 12:30 p.m. and 3:30 p.m., revealed that the towel warmer was plugged in and unlocked. The temperature reading during these observations was 180 degrees Fahrenheit. During the initial tour of the facility on December 21, 2015 at approximately 1:00 p.m., an observation was made in an unlocked utility room across the hallway from the medication room. An unlocked cabinet in the utility room was observed to contain a quarter of a quart spray bottle of disinfectant solution and two quart spray bottles of window cleaner half filled. These products contained label warnings to keep out of the reach of children. Resident B8's care plan indicated that the resident had wandering behavior and impaired cognition secondary to dementia. On all days of the survey, the resident was seen wandering in the hallways with possible access to both areas. The Nursing Home Administrator confirmed on December 23, 2015 at 2:45 p.m., that according to facility policy, the towel appliance should have been unplugged and locked and that the chemicals should be stored in a locked cabinet. F323 483.25 Quality of Care Previously cited 1/02/15 28 Pa. Code 201.18 (b)(1) Management. Previously cited 1/02/15 28 Pa. Code 211.10(d) Resident care policies.

Based on review of facility policy, review of clinical records, facility documentation, and staff interview it was determined that the facility failed to provide adequate supervision and monitoring to ensure the safety of residents at risk for falls for four of 13 residents reviewed (Residents A7, B3, B8, and C6) and to ensure that treatments and supplies were secured in one of two medication rooms. Findings include: Review of facility policy "Falls: Completion of Incident Report", reviewed December 2013, revealed that new interventions must be completed on the incident/accident report and the shift supervisor will add the new intervention to the resident's care plan. Review of facility policy "Accidents and Supervision" reviewed December 2013, indicated that a falls committee comprised of members of the interdisciplinary team monitors and evaluates falls and makes recommendations to prevent injury. Once a week, members of the interdisciplinary team meet to discuss individual resident needs and adjust the care plan. Monitoring of accidents and hazards is conducted on a regular basis to ensure that interventions are effective, and/or modified as necessary to better meet individual resident needs. Review of Resident A7's annual Minimum Data Set (assessment of resident care needs and status), dated October 30, 2013, indicated that the resident had moderate cognitive impairment and included [DIAGNOSES REDACTED]. Review of the care plan dated January 17, 2014, revealed that the resident is at risk for falls/injury related to muscle weakness and unsteadiness. The care plan stated, Resident A7 has a history of severe spinal stenosis, chronic pain, and ambulation dysfunction. Review of the fall risk assessment dated [DATE], indicated that the resident was at moderate risk for falls. Review of facility documentation revealed that Resident A7 had nine falls from April 9, 2014 to December 13, 2014. Review of interdisciplinary notes and facility documentation revealed that on April 9, 2014, at 12:30 a.m., the resident was found on the floor outside the bathroom door. The care plan intervention instructed staff to assure needs are met before leaving the room and for the resident to use the call bell. Review of the fall risk assessment dated [DATE], revealed that the resident was at moderate risk for falls. The resident was found on the bathroom floor on July 13, 2014 at 2:45 a.m. and the intervention was to encourage the resident to use call bell and walker. The resident fell out of bed on July 29, 2014, at 9:25 p.m. with no new intervention documented. The resident was again found on the floor beside the bed on September 14, 2014, at 3:50 p.m. and November 5, 2014, at 3:30 a.m., resulting in ecchymosis of the right eye orbit. Review of care plan dated November 5, 2014, indicated all approaches reviewed and appropriate at this time, resident alert and oriented, but forgetful; educated to use call bell for assistance. On November 7, 2014, the resident was on the floor outside the bathroom, sustaining a laceration on the palm of his hand and was reminded to ring for assistance after toileting. There was no indication that the facility put other interventions or increased supervision when the resident repeatedly fell on the bathroom floor or out of bed and the resident did not use the call bell. Review of Resident B3 ' s significant change assessment dated [DATE], revealed that the resident had severe cognitive impairment and [DIAGNOSES REDACTED]. (progressive disease of the central nervous system characterized by tremors, muscle weakness and unsteady gait), and difficulty walking. Review of the fall risk assessment dated [DATE]; indicated resident was a high risk for falls. Review of current care plan indicated the resident is at risk for falls/injury related to unsteadiness due to Parkinson ' s disease and poor safety judgment due to dementia. Review of facility documentation revealed that the resident fell on [DATE], at 9:15 a.m. attempting to sit in the recliner; care plan reviewed. Resident was found on the bathroom floor on September 26, 2014, at 6:30 a.m. with no new interventions implemented. Resident was found on the floor on November 14, 2014, at 10:40 p.m. with the chair turned over on his right arm; care plan reviewed. Resident was found on the floor on December 16, 2014, at 12:00 p.m. in the dining room; the intervention implemented was to check frequently when the resident was in his room, even though the fall occurred in the dining room. Resident was found on the floor at bedside on December 24, 2014, at 4:00 a.m.; no new interventions implemented. Review of Resident B8 ' s significant change assessment dated [DATE], revealed that the resident has severe cognitive impairment and [DIAGNOSES REDACTED]. Review of the current care plan revealed a potential for falls due to poor safety awareness, decline in mobility and history of fractured pelvis, weak legs, poor endurance and unsteadiness. Review of facility documentation revealed that the resident was found on the floor between the chair and the bed on March 19, 2014 at 8:10 a.m.; care plan reviewed. Resident found sitting on floor on May 23, 2014, at 12:00 a.m.; educated to use call bell. Resident was found on the floor on September 5, 2014, at 5:00 a.m.; resident reminded to use call bell. Resident was found on the floor on September 25, 2014, at 7:15 a.m.; asked resident to ring call bell for assistance. Resident was found on the floor on December 16, 2014, at 6:30 a.m. , the call bell was ringing; intervention implemented was to encourage the resident to use the call bell. No new interventions or increased supervision was implemented Review of Resident C6's [DIAGNOSES REDACTED]. The resident's quarterly MDS (assessment of resident care needs and status) dated November 26, 2014 revealed that the resident had moderate cognitive ability (thinking ability). The resident's fall risk assessment dated [DATE] and August 27, 2014 revealed that the resident was at high risk for falling. The physician wrote in a progress note dated December 26, 2014 that the resident was at high risk of falling. On November 25, 2014 facility documentation revealed that the Resident C6 was found at approximately 4:00 p.m. sitting on the floor in front of his wheelchair. Review of the care plan did not indicate any changes to the fall care plan. On November 29, 2014 at approximately 4:50 a.m., progress notes indicated that the resident was heard falling in his room. On November 30, 2014 the progress notes revealed that the resident was found on the floor in the bathroom at 2: 45 a.m. Review of the fall care plan did not reveal any changes to address these two falls. On December 3, 2014 facility documentation indicated that Resident C6 sustained a fall in his room at 3:00 a.m. and the care plan indicated that staff would continue to check him every half hour. Review of progress notes dated December 5, 2014 revealed the resident had a witnessed fall in the lounge after tripping over his wheelchair pedals at 9:15 a.m. Review of the care plan revealed that staff were educated to maintain a clear path for resident. Review of the progress notes on December 6, 2014 revealed that the resident was found at 12:30 a.m. on his knees in the bathroom. The resident had sustained an abrasion to his forehead and hand. The care plan failed to reveal any additional interventions to address this fall. On December 8, 2014 at 11:30 p.m. Resident C6 was found on the floor behind the bathroom door. Documentation indicated that staff reviewed the care plan however there were no additional interventions added. Review of progress notes revealed that Resident C6 sustained falls on December 21 at 4:45 p.m. and December 24, 2014 at 9:30 p.m. and review of the fall care plan did not reveal any interventions to address these falls. On December 25, 2014 at 5:15 a.m. the progress notes indicated that the resident came out of his room and told staff that he had fallen and pointed to the edge of the dresser. Staff assessment revealed that the resident had sustained lacerations to the nose and left eyebrow and a bruise to the left shoulder. Review of the care plan failed to reveal any additional interventions to address Resident C6 ' s 10 falls sustained in 30 days from November 25, 2014 to December 25, 2014. Licensed nurse, Employee E2 confirmed during an interview on December 31, 2014 at 10:30 a.m. that staff review the care plans after a fall, but new interventions are not always implemented. Review of facility policy entitled Medication Storage revised May 2010 revealed that all medications and other drugs including treatment items, shall be stored in a locked cabinet, cart, refrigerator or room, inaccessible to residents, unauthorized facility personnel and visitors. All medications and sharps are maintained in a locked room. Observation of the medication room closest to the nursing station during the initial tour of the facility on December 29, 2014 at 12:30 p.m. revealed that the door was unlocked. The treatment cart was stored in the medication room and was also unlocked. All four drawers were accessible and contained numerous treatment ointments. These ointments included: ketoconazole shampoo ( an anti-infective shampoo), nystatin topical powder (antifungal/antibiotic powder), Santyl ointment (debriding ointment used to clean wounds), Calmoseptine ointment (antiseptic/antiitch ointment), fluocinonide ointment (topical corticosteroid) and compro suppositories ( used for nausea). In addition to the unlocked treatment cart, an unlocked drawer in the medication room contained barber scissors, 6 inch shears and four nail clippers. Observation of the same medication room on December 30, 2014 at 10:00 a.m. by two surveyors, revealed that the room was again unlocked. The treatment cart and the drawer containing sharps were unlocked and unsupervised. The Nursing Home Administrator confirmed on December 30, 2014 at 3:00 p.m. that the treatment cart and the medication room should have been locked as stated in the facility policy to assure a safe environment. 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 211.5(f) Clinical records Previously cited 12/23/2013 28 Pa. Code: 211.11(d) Resident care plan 28 Pa. Code: 211.12(d)(1)(5) Nursing services