Every finding on record at Kirkland Village

Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide the necessary supervision to monitor a resident's location and prevent an elopement (unauthorized departure from the facility) for one of five sampled residents (Resident 1), This failure resulted in an Immediate Jeopardy situation. The incident has been identified as past non-compliance. Findings include: Review of the facility policy entitled, Elopement, last reviewed on December 29, 2025, revealed that staff were to monitor residents to prevent elopement. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included infection and inflammatory reaction due to an indwelling catheter (a tube inserted into the bladder to drain urine), abnormalities of gait and mobility, and muscle weakness. According to the Minimum Data Set assessment (MDS, a periodic evaluation of resident care needs) dated January 28, 2026, the resident had memory impairment and required partial assistance to walk. According to the current care plan, the facility identified that the resident could walk with a front wheeled walker and assistance from one staff member. Nursing documentation indicated that on February 14, 2026, a nurse noted that Resident 1's family informed the facility that they could not locate Resident 1 when they came for a visit at 11:44 a.m. Review of facility documentation, dated February 14, 2026, revealed that the resident was located at 12:30 p.m. in the parking garage of the [NAME] Independent Living Apartments, which is not part of the skilled nursing units. It is located at the opposite end of a connected building. Emergency 911 was called and Resident 1 was taken to the hospital for evaluation. Review of the facility investigation revealed that Resident 1 was last seen by staff at 10:00 a.m. walking in the hall of the skilled nursing facility. The investigation revealed that Resident 1 was found lying on the concrete garage floor, stating he was cold, with skin tears on his left foot/toes, left leg, and both elbows and dried blood on the back of his head. The resident also had a scalp laceration (cut) that required two staples. The facility was not aware of Resident 1's location or that he had left the facility for one hour and 45 minutes. In an interview on February 18, 2026, at 10:30 a.m., the Administrator stated that they believed Resident 1 exited through the unmonitored, unlocked doors to the Independent Living section of the building and made his way down the hall to the elevator that led to the parking garage. There was no evidence that the doors to exit the skilled nursing facility were alarmed, locked, or monitored, and residents at risk for elopement had access to this area. On February 18, 2026, at 12:27 p.m., the Administrator was notified that the failure to provide adequate supervision to prevent elopements constituted an Immediate Jeopardy situation at F689-J, and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility identified the jeopardy at the time of the incident, February 14, 2026, at 11:44 a.m., and implemented the following corrective action plan: 1. Resident 1 was assessed by a licensed nurse and sent to the hospital for evaluation.2. All facility residents had a new elopement assessment completed on February 14, 2026. All residents at risk for elopement were communicated to staff and had their care plans/interventions updated on February 14, 2026.3. All safety devices were checked to ensure they were in place, including electronic devices applied to at risk residents to prevent doors from opening (Wander Guard system). 4. An audit was conducted on February 14, 2026, of all skilled nursing community exits.5. On February 14, 2026, a staff member was placed to observe any exits that are not locked at all times until the facility's vendor completes the installation of new locking mechanisms.6. All staff were re-educated on February 14 and 15, 2026 on the elopement policy and that staff must monitor the exit doors at all times until the locking mechanisms are installed.7. The Director of Nursing or designee was to initiate weekly audits and report results to the QAPI (Quality Assurance, Performance Improvement) committee. The first audit was done on February 15, 2026.On February 18, 2026, a review was conducted to verify the complete implementation of the facility's corrective action plan. All staff interviewed confirmed that they received the training described in the facility's action plan. All nursing staff were aware of the requirements for supervising residents who were at risk for elopement. All facility doors and safety devices (Wander Guards) were checked and were functioning properly. Staff was observed monitoring exit doorways. All sampled residents were being supervised by staff when needed. All training was completed by February 15, 2026. The Immediate Jeopardy existed on February 14, 2026, from 11:44 a.m. until February 15, 2026, at 6:30 p.m. Verification of all elements of the action plan was completed on February 18, 2026, at 1:00 p.m., and the Immediate Jeopardy was officially lifted effective February 15, 2026. The Nursing Home Administrator and the Director of Nursing were informed that residents were no longer considered to be in immediate jeopardy. 28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, staff interview, and clinical record review, it was determined that the facility failed to adequately monitor and assess a significant weight change for one of 12 sampled residents. (Resident 11) Findings include: Review of the facility policy entitled, Nutrition Risk Identification, last reviewed August 29, 2024, revealed that the nursing or dietary department would identify residents with a weight loss of five percent total body weight in a 30 day period and a dietician would complete a nutritional evaluation and recommend any changes needed to aid the resident's return to optimal nutritional status. In an interview on September 12, 2024, at 12:10 p.m., the Administrator stated that nursing staff were to obtain a resident's weight and relay any changes to the dietitian. Clinical record review revealed that Resident 11 had diagnoses that included dementia, adult failure to thrive, and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had severe cognitive impairment. Review of the current care plan revealed that Resident 11 was at nutritional risk with an intervention for staff to monitor weights. Review of the resident's weights revealed that on July 4, 2024, the resident weighed 146 pounds (lbs). On August 13, 2024, Resident 11 weighed 124.6 lbs, which was confirmed with a reweigh. On August 19, 2024, Resident 11 weighed 125 lbs. There was no documented evidence that the dietitian addressed the significant weight loss. In an interview on September 12, 2024, at 12:07 p.m., the Administrator confirmed that there was no documented evidence that the dietitian addressed the significant weight loss. 28 Pa. Code 211.10(a)Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5)Nursing services.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to implement transmission based droplet precautions and use of personal protective equipment (PPE) to prevent the spread of infection for two of 12 sampled residents. (Residents 15, 23) Findings include: Review of the facility policy entitled, Covid-19 PPE Policy, last reviewed on August 29, 2024, revealed that staff was to wear cleanable or disposable eye wear, non-sterile, disposable isolation gowns, respirator type face masks, and gloves, which were donned and doffed when entering and exiting patients' room and were not to be reused. Review of the facility policy entitled, Droplet Precautions, last reviewed on August 29, 2024, revealed that staff were to clean their hands before entering and when exiting the room, to make sure eyes, nose, and mouth were fully covered before room entry, and to remove face protection before exiting the room. Clinical record review revealed that Resident 15 tested positive for Coronavirus disease 2019 (COVID-19) on September 1, 2024. Review of the care plan revealed that Resident 15 had a recently confirmed case of COVID-19, and that staff were to follow droplet isolation precautions that included gown, gloves, eye protection and an N95 grade respirator. Observation on September 11, 2024, at 10:01 a.m., revealed a food server (S1) entered Resident 15's room while wearing a surgical face mask. S1 did not have on the required PPE and did not remove her face mask when she exited the room at 10:06 a.m . On September 11, 2024, at 10:08 a.m., Registered Nurse (RN1) was observed entering Resident 15's room for six minutes wearing a surgical face mask. RN1 did not have on the required PPE. RN1 was observed giving the resident her medications and exiting the room at 10:14 a.m RN1 did not remove her face mask when she exited the room. Clinical record review revealed that Resident 23 had tested positive for COVID-19 on September 10, 2024, and was on droplet precautions. Review of the care plan revealed that Resident 23 had a recently confirmed case of COVID-19, and staff were to follow droplet isolation precautions. On September 11, 2024, at 9:58 a.m., RN1 was observed entering Resident 15's room while wearing a surgical face mask. RN1 did not have on the required PPE. RN1 was observed giving the resident her medication and exiting the room at 10:03 a.m . RN1 did not remove her face mask when she exited the room. In an interview on September 11, 2024, at 2:47 p.m., the Administrator confirmed that droplet and COVID-19 PPE precautions should have been implemented and the policies were not being followed by staff. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of 12 sampled residents. (Resident 20) Findings include: Clinical record review revealed that Resident 20 had diagnoses that included chronic kidney disease and heart failure. On June 14, 2024, a physician ordered that staff obtain a daily weight for the resident. A review of Resident 20's weights revealed that there was no documented evidence to support a weight was obtained on September 5, 6, 7, and 8, 2024. In an interview on September 12, 2024, at 11:10 a.m., the Administrator confirmed there was no documentation to support that weights were obtained by staff or refused by Resident 20 on the previously mentioned dates. CFR 483.25 Quality of Care Previously cited 10/26/23 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to notify a resident's responsible party of a significant weight loss for one of 12 sampled residents. (Resident 11) Findings include: Review of the facility policy entitled, Change in Medical Condition, dated August 29, 2024, revealed that staff were to provide timely notification to the resident's representative of significant changes to the resident's physical status. Clinical record review revealed that Resident 11 had diagnoses that included dementia, adult failure to thrive, and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had severe cognitive impairment. Review of the resident's weights revealed that on July 4, 2024, the resident weighed 146 pounds (lbs). On August 13, 2024, Resident 11 weighed 124.6 lbs, which was confirmed with a reweigh. On August 19, 2024, Resident 11 weighed 125 lbs. This reflected a 14 percent weight loss in one month. There was no documented evidence that Resident 11's responsible party was notified of the significant weight loss. In an interview on September 12, 2024, at 12:07 p.m., the Administrator confirmed that there was no documented evidence that Resident 11's responsible party was notified of the significant weight loss. Pa. Code 201.29(c) Resident rights.

Based on clinical record review, facility policy review, and staff and resident interviews, it was determined that the facility failed to assess and treat wounds for one of 13 sampled residents. (Resident 94) Findings include: Review of the facility policy entitled, Wound Prevention and Wound Care, last reviewed January 6, 2023, revealed that information regarding increased risk for skin breakdown should be obtained prior to resident admission and upon admission a skin assessment would be completed weekly for one month to assess changing risk for skin breakdown. The registered nurse would assess, document, and notify the physician of a new wound. Clinical record review revealed that Resident 94 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus, end stage renal disease, and hypertension. Review of Resident 94's discharge documentation from the hospital revealed that he had wounds to his left elbow and sacrum. In an interview on October 24, 2023, at 11:30 a.m., Resident 94 stated that he was concerned with pain in his left elbow and wound treatments to his sacrum. He stated that no one has looked at his wounds or provided treatments to them since admission. Resident 94's left elbow was observed at that time and revealed a bandage dated October 19, 2023. Resident 94 further stated that the bandage was placed on his elbow at the hospital prior to admission. There was no documented evidence that the facility assessed Resident 94's wounds, notified the physician, or provided treatments until October 24, 2023, for his sacral wound and October 25, 2023, for his left elbow. In an interview on October 26, 2023, at 9:15 a.m. the Director of Nursing stated that staff were to assess a resident's skin on admission and that there was no documentation to support that Resident 94's wounds were assessed or treated prior to October 24 and 25, 2023. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, review of facility documentation, observation, and staff interview, it was determined that the facility failed to implement safety interventions for one of three sampled residents at risk for falls. (Resident 11) Findings include: Clinical record review revealed that Resident 11 was admitted to the facility on [DATE], and had diagnoses that included Parkinson's disease. On August 5, 2023, the resident fell out of bed and was found on the floor. On August 7, 2023, the risk team reviewed the incident and implemented fall mats to each side of the bed as an intervention to prevent injury. Review of the current care plan revealed that the resident was at risk for falls and an intervention for staff to apply fall mats to each side of her bed was implemented on August 7, 2023. On August 17, 2023, Resident 11 was found lying next to her bed on the floor. A nurse's note dated August 17, 2023, revealed that the facility had contacted hospice for fall mats. On September 7, 2023, Resident 11 was found lying on her back beside her bed on the floor. On September 22, 2023, Resident 11 was found on the floor next to her bed. Review of the facility's incident documentation for Resident 11's falls from August 17, 2023, through September 22, 2023, revealed no documented evidence that the fall mats to both sides of the resident's bed were in place at the time of the falls. Observations on October 24, 2023, from 11:00 a.m. through 2:00 p.m., and on October 25, 2023, from 9:15 a.m through 9:40 a.m., revealed Resident 11 in bed without fall mats to each side of her bed. In an interview on October, 26, 2024, at 11:00 a.m. Registered Nurse 1 stated that there was no documented evidence that fall mats were in place during the time of Resident 11's falls. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to maintain clinical records that were accurate and complete for two of 13 sampled residents. (Residents 7, 42) Findings include: Clinical record review revealed that Resident 7 had diagnoses that included diabetes. A physician's order dated [DATE], directed staff to administer six units of a diabetes medication (insulin aspart) with each meal when blood glucose level (BGL) (the measurement of sugar found in one's blood) was greater than 100 milligrams per deciliter (mg/dL). A physician's order dated [DATE], directed staff to administer an additional number of insulin aspart units with each meal based on a scale of how much over 150 mg/dL the BGL was at that time. A review of Resident 7's medication administration record revealed that the staff documented the total amount of insulin aspart given to Resident 7 in two places in the administration record 51 of 143 times. In an interview on [DATE], at 1:20 p.m., the Director of Nursing confirmed that staff did not properly document the amount of insulin they gave in the clinical record. Clinical record review revealed that Resident 42 was admitted to the facility on [DATE], with diagnoses that breast cancer and congestive heart failure. A nurse's note dated [DATE], indicated that the resident was resting in bed and had no pain. In an interview on [DATE], at 9:05 a.m., the Director of Nursing stated that the resident died in the facility on [DATE], on hospice. There was a lack of evidence to support that facility staff documented Resident 42's change in condition and notification to the physician and resident representative. In an interview on [DATE], at 9:06 a.m., the Director of Nursing stated that the facility had no documentation to support that staff documented the change in condition for Resident 11 or notification to the physician and resident representative. 28 Pa. Code 211.5(f) Medical records.

Based on review of the Resident Assessment Instrument (RAI) User's Manual, clinical record review, and staff interview, it was determined that the facility failed to timely complete a quarterly Minimum Data Set (MDS) assessment for one of 13 sampled residents. (Resident 21) Findings include: The Long Term Care Facility RAI User's Manual which provides instructions and guidelines for completing required MDS assessments, (mandated assessments of a residents' abilities and care needs), revised October 2023, indicates that quarterly assessments are to be completed no longer than the Assessment Reference Date (ARD) which refers to the last day of the observation for the look back period that the assessment covers for the resident plus 14 calendar days. Clinical record review revealed that Resident 21 had a quarterly MDS assessment completed on May 24, 2023. Review of the MDS assessments revealed no evidence that any MDS assessment, including a quarterly assessment, had been completed since May 24, 2023. In an interview on October 25, 2023, at 3:18 p.m., the Nursing Home Administrator stated that the MDS quarterly assessment had not been completed in a timely manner as required by the RAI manual.

Based on clinical record review, staff interview and resident interview, it was determined that the facility failed to ensure that a resident's call bell was answered in a timely manner for one of four sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included acute cystitis with hematuria (inflammation of the bladder) and bilateral leg weakness. Review of the Minimum Data Set assessment, dated October 26, 2022, revealed that Resident 1 was able to communicate their needs, had no cognitive impairment, and required extensive assistance from staff with activities of daily living. Review of the care plan revealed that Resident 1 had physical limitations and was at risk for falls. The interventions included that staff ensure the call bell was within reach and encourage use of the call bell for assistance. In an interview on October 28, 2022, at 11:40 a.m., the Nursing Home Administrator stated that call bells were expected to be answered within ten minutes. Review of the facility form entitled, Alarm History from October 24, 2022, to October 27, 2022, revealed ten occurrences when the call bell response time exceeded more than ten minutes, with the highest being one hour thirty minutes. In an interview on October 28, 2022, at 12:30 p.m., Resident 1 stated that it takes long periods of time for staff to answer call bells and get assistance. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to implement care planned interventions for one of 14 sampled residents. (Resident 139) Findings include: Review of the facility policy entitled Weights, last reviewed January 13, 2021, revealed staff was to ensure all residents were weighed on the day of admission and weekly for four weeks thereafter. A licenced nurse or nurse aide was to record the weights in the clinical record. Clinical record review revealed that Resident 139 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE], revealed that the resident received nutrition through an enteral feeding tube (a tube that goes directly to the stomach or small intestine). According to the current care plan, the resident was at risk for nutrition problems and staff was to weigh the resident weekly. Review of the clinical record revealed that the resident was only weighed on admission and once after. There is no documented evidence that the resident was weighed weekly according to the care plan and facility policy. In an interview on November 24, 2021, at 11:50 a.m., the Administrator confirmed that the resident had not been weighed in accordance with her care plan and facility policy. 28 Pa. code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a resident received necessary restorative nursing services to increase range of motion or prevent a further decrease in range of motion for one of 12 sampled residents. (Resident 9) Findings include: Clinical record review revealed that Resident 9 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE], indicated that the resident required extensive assistance from staff for activities of daily living and had functional limitations in range of motion of all extremities. The physical therapy discharge plan dated September 27, 2019, recommended a functional maintenance program and the resident's current care plan directed that she would participate with restorative nursing for active range of motion (AROM), as tolerated. Record review revealed that the resident was diagnosed with [REDACTED]. Resident 9's most recent Physical therapy and occupational therapy screenings completed May 7, 2020, indicated that the resident was at her prior level of functioning with no new changes. In an interview conducted on November 10, 2020, the Rehabilitation Manager stated that there was no recommended change in treatment at the time of the screenings. During an interview on November 10, 2020, the Director of Nursing stated that the resident's AROM restorative program had been stopped due to the onset of the resident's illness on May 5, 2020. Review of the clinical record revealed that the resident was moved back to her previous nursing unit on July 29, 2020, and was not displaying related symptoms at that time. There was a lack of documentation to support that the resident was reassessed for restorative nursing services or that AROM was provided to the resident after May 6, 2020. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation, staff interview, and policy review, it was determined that the facility failed to properly store food to prevent potential foodborne illness. Findings include: Review of the facility policy entitled Prepared Foods, dated [DATE], revealed that staff was to ensure labeling/dating of products to prevent foodborne illness and ensure quality of food products. Observation in the dry storage area during the initial tour of the kitchen on [DATE], at 8:30 a.m., revealed ten packets of hot dog buns with an expiration date of [DATE]. Observation of the cold storage refrigerator on [DATE], at 8:45 a.m., revealed an open container of lemon vinaigrette dressing with no open date, six containers of sweet apple cider with a use by date of [DATE], a container of whipped cream with a use by date of [DATE], and an open container of Dijon honey dressing with a use by date of [DATE]. In an interview on [DATE], at 8:55 a.m., the Produce Manager stated that staff was to rotate stock and discard expired food items. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 207.2(a) Administrators responsibility.

Based on clinical record review, policy review and interview, it was determined that the facility failed to ensure that residents were provided the right to participate in the formulation of an advance directive to determine what medical interventions were desired if not able to make a decision when needed or that the resident's advance directive was clearly identified for three of 18 sampled residents. (Residents 6, 15, 33) Findings include: Review of the facility policy entitled, Advance Directives, dated (MONTH) 7, 2019, revealed that all residents had the right to information concerning the formulation of advance directives and to have their decisions regarding medical treatments respected. The policy also stated that the resident was to be encouraged to execute a written declaration indicating the desire for a physician to initiate, continue, withhold or withdraw certain life-sustaining medical treatments in the event the resident becomes incompetent and the resident was permanently unconscious or had an end-stage medical condition. Clinical record review revealed that Resident 15's record had a form signed by the physician and the resident's daughter directing that the resident not be resuscitated. In an interview on (MONTH) 5, 2019 at 2:50 p.m., LPN1 stated that staff check the physician's order and that gets carried over to the Medication Administration Record [REDACTED]. Review of the MAR for Resident 15 revealed do not resuscitate. The Minimum Data Set (MDS) assessment, dated (MONTH) 18, 2019, indicated that the resident was alert and oriented with no memory problems. In an interview on (MONTH) 5, 2019, at 2:39 p.m., Resdient 15 stated that she was unaware of the right to formulate an advance directive and had not been asked the type of care that would be desired should she become unable to make the decision. The resident then stated that cardiopulmonary resuscitation (CPR) would be desired in the event that it was needed. There was a lack of documentation to support that the resident was provided the opportunity to participate in decisions regarding an advance directive or that the resident was in agreement with the do not resuscitate order. Clinical record review revealed that Resident 6 was admitted to the facility on (MONTH) 30, 2019. The hospital transfer form of the same date indicated that the resident had an advance directive of no resuscitation and that a copy was available. The current physician's order, dated (MONTH) 30, 2019, indictaed that the resident was full code, reflecting that all life-saving measures be implemented if needed. There was a lack of documentation to support that the facility had provided advance directive information to the resident and/or responsible party or had attempted to clarify the advance directive status of the resident. Clinical record review revealed that Resident 33 had a current physician's order, signed (MONTH) 28, 2019, indicating that the resident was full code. However, there was a living will executed by the resident on (MONTH) 20, (YEAR), indicating that no resuscitation was desired. In addition, the clinical record also included a request to not resuscitate the resident signed by the responsible party on (MONTH) 5, 2019, and signed by the physician on (MONTH) 7, 2019. There was a lack of documentation to support that the facility had clarified the resident's conflicting advance directive. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited [DATE]

Based on clinical record review, it was determined that the facility failed to ensure that a resident with a history of heart problems received proper care as ordered by the attending physician for one of 18 sampled residents. (Resident 33) Findings include: Clinical record review revealed that Resident 33 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated (MONTH) 16, 2019, indicated that the resident required staff assistance for daily activities and care. Nursing documentation noted that the resident received [MEDICATION NAME] (a diuretic medication) 10 milligrams on (MONTH) 17, 18, and 19, 2019, to treat fluid retention. On (MONTH) 24, 2019, the physician increased the [MEDICATION NAME] to 20 milligrams daily for [MEDICAL CONDITION] and that staff were to notify the physician if the resident's weight changed three pounds in one day or five pounds in one week. Review of the resident's daily weights revealed that the resident had experienced a three pound weight gain in one day on (MONTH) 20, 2019, and (MONTH) 28, 2019. There was a lack of evidence to support that the physican had been notified of the weight gain on those two occasions. On (MONTH) 29, 2019, the resident gained an additional six pounds (nine pounds in two days). A nurse's note of the same date at 10:22 a.m., revealed that the resident had +3 [MEDICAL CONDITION] of both lower legs and crackling in the right lower lung. The resident was assessed by the nurse practitioner and diagnosed with [REDACTED]. 28 Pa. Code 211.12(d)(1) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/17/18

Based on clinical record review, observation, policy review and staff interview, it was determined that the facility failed to ensure that transmission based precautions were maintained for one of four sampled residents with an infection. (Resident 60) Findings include: Review of the facility policy entitled, Contact Precautions, dated (MONTH) 27, (YEAR), revealed that staff were to instruct a resident who had an infection on the need for precautions to prevent the spread of the infection. Review of Center for Disease Control and Prevention guidelines revealed that Healthcare providers were to put on gloves and wear a gown over their clothing (contact precautions) while taking care of individuals who had [MEDICAL CONDITION] (C. diff, a bacteria of the intestinal tract) infection. Clinical record review revealed that Resident 60 was readmitted to the facility with a [DIAGNOSES REDACTED]. A nursing progress note dated (MONTH) 12, (YEAR) revealed that Resident 60 was alert and oriented and able to make decisions independently. Review of physician's orders revealed that on readmission, Resident 60 was ordered an antibiotic ([MEDICATION NAME]) to treat the [DIAGNOSES REDACTED]. Observation of Resident 60's room on (MONTH) 15, (YEAR) at 11:40 a.m., revealed that there was no sign outside of the doorway to contact the nurse before entering the room and that there was no protective personal equipment outside or inside Resident 60's room for staff/visitors to utilize when providing care or visiting with the resident. In an interview on (MONTH) 15, (YEAR), at 11:30 a.m. RN1 stated that Resident 60 was on contact precautions due to [DIAGNOSES REDACTED]. In an interview on (MONTH) 15, (YEAR), at 1:25 p.m., Resident 60 and his wife stated that they had not been informed that the resident was on contact precautions and that they had not been educated on infection precautions that were to be in place. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to maintain a refrigerator to ensure food was stored at a safe temperature (41 degrees Farenheit or below) on one of two nursing units. (Rabold nursing unit) Findings include: On June 13, 2017, at 9:45 a.m. the refrigerator used for storage of food items for service to residents on the Rabold nursing unit registered a temperature of 52 degrees Farenheit. The refrigerator contained three containers of thickened milk, bread and a cake. One of the thickened milk containers was open with directions on the packaging to refrigerate after opening. In the presence of the Food Service Manager the temperature of the opened thickened milk was obtained and registered 54 degrees Fahrenheit. In an interview at that time, the Food Service Manager stated that he could not produce any evidence to support that staff had been monitoring the temperature of the refrigerator to ensure that safe temperatures were being maintained. CFR: 483.60(i) Food Safety requirements. Previously cited 5/19/16

Based on observation, it was determined that the facility failed to ensure that food was stored in a sanitary manner in the kitchen. The facility also failed to ensure that food was served under sanitary conditions on one of two nursing units. Findings include: During the initial environmental tour of the food service department on May 17, 2016, at 8:45 a.m., a scoop was stored directly in a container of panko in the dry storage area. On May 18, 2016, at 8:15 a.m., Employee 1 was plating food from the steam table for the residents in the dining room on the Rabold unit without a hairnet.

Based on clinical record review and staff interview, it was determined that the facility failed to provide assessed nutritional interventions to maintain acceptable nutritional parameters for two of 14 residents sampled with weight loss. (Resident R11, R36) Findings include: Clinical record review revealed that Resident R11 had a [DIAGNOSES REDACTED]. On April, 5, 2016 a nutrition assessment was completed indicating that the resident had not been eating well and that she had a 4.6% weight loss in one week. The nutrition intervention included a calorie count to begin on April 6, 2016. There was no evidence to support that the calorie count was completed. On April 18, 2016, the resident's weight record reflected a weight loss of seven percent in one month. Clinical record review revealed that Resident R36 had [DIAGNOSES REDACTED]. Nursing documentation indicated the resident had difficulty swallowing, was involved with speech therapy, and the resident received a soft diet. On March 22, 2016, the care plan identified the resident at nutritional risk for weight loss an intervention was recommended to complete a calorie count. Review of the nutritional assessment completed on March 24, 2016, by the dietitian revealed that the resident's weight indicated a three month 12% weight loss, and that the goal was to promote weight stability. There was a lack of evidence that the calorie count was completed to support that the resident's intake was sufficient to met her nutritional needs. In an interview on May 19, 2016, at 9:45 a.m., the Director of Nursing confirmed that calorie counts had not been completed for Residents R11 and R36. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on clinical record review, it was determined that the facility failed to timely administer physician ordered pain medication to one of three sampled residents with pain. (Resident CR1) Findings include: Clinical record review revealed that Resident CR1 had [DIAGNOSES REDACTED]. An initial Minimum Data Set (MDS) assessment dated [DATE], identified that the resident was cognitively intact and experienced periods of occasional moderate pain. A physician's orders [REDACTED]. On September 5, 2015, a nurse documented that Resident CR1 was discovered on the floor at 4:15 p.m. According to the note, the resident started complaining of hip and leg pain fifteen minutes after being found on the floor. There was no evidence to support that the resident was offered the pain medication until 7:04 p.m., and at that point the resident was documented as having moderate pain. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on one of four clinical records reviewed, and staff interview, it was determined that the facility failed to ensure that staff periodically removed a protective dressing to monitor a resident's skin integrity. As a result of this failure, staff failed to timely identify and treat a wound which had developed. (Resident R53) findings include: Clinical record review revealed that [AGE] year old Resident R53 had been admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. A Minimum Data Set quarterly review assessment dated [DATE], reflected that the resident had impaired memory and decision making ability, and was dependent on staff for transfers, ambulation,and bed mobility. The assessment also indicated that the resident was at risk for pressure ulcer development. Documentation by the podiatrist on December 9, 2010, and February 17, 2011, indicated that the resident's feet showed signs of [MEDICAL CONDITION]. (This meant the resident had impaired circulation in her feet, and therefore was at risk of foot infections that could progress to gangrene, i.e., tissue death, which in turn could ultimately necessitate amputation of the affected limb.) Clinical record documentation revealed that on November 22, 2010, the nurse took a telephone order from the physician for staff to apply a pad to the resident's right heel "at all times." Clinical record documentation reflected that this order continued to be in effect throughout the resident's stay until she was transferred to the hospital on March 1, 2011. Interviews on March 8, 2011, at 2:25 PM with Employee 1, a registered nurse, and Employee 2, a licensed practical nurse, revealed that staff had applied a protective, non-adhesive, pad to the resident's right heel and wrapped the heel with gauze to hold the pad in place. Both nurse's said that the facility routinely used this measure to protect bony prominences, such as a heel or elbow. Review of Resident R53's treatment sheet for February 2011 revealed that staff had documented that the pad was in place on the resident's right heel on every shift throughout that month. However, there was a lack of evidence that staff had removed the dressing periodically to monitor the resident's skin. During the aforementioned interview, Employees 1 and 2 said that when a resident had one of these protective pads applied, staff were to routinely remove the gauze dressing and pad every three days, to check the resident's skin. There was a lack of documentation in Resident R53's clinical record to support that this had been done. On March 1, 2011, at 3:03 PM, Employee 2 had documented in the nurse's notes that the resident had a wound on her "right outer foot" and that there was foul smelling, copious tea colored drainage coming from the wound. During the aforementioned interview, Employee 2 said that the wound was below the resident's right ankle. Employee 2 said that she had found the wound when she had brought some fluid to the resident, who was sitting in the wheelchair, and then noted a foul odor. Employee 2 said that the odor was coming from the resident's right foot. She said that the resident had on a sock, and that she removed this. Employee 2 said that the part of the resident's right foot that was visible appeared unremarkable, but she noted that the posterior foot and heel, and lower leg just above the ankle, was wrapped in gauze. Employee 2 said that she removed the gauze and the heel pad, and found a large, draining wound. Employee 2 said that the nurse practitioner was notified. Review of the nurse practitioner's progress noted that day revealed that on the resident's right lateral malleolus (ankle) there was a "large wound," 6 centimeters by 4 centimeters, with "black eschar" (dead tissue) with surrounding [DIAGNOSES REDACTED] (the skin around the wound was red). The nurse practitioner noted that the wound was "foul smelling." The nurse practitioner noted that the area had been covered with a heel pad and a dressing. The nurse practitioner documented that the wound was infected. Clinical record documentation reflected that the resident was transferred to the hospital where it was determined that she had [MEDICAL CONDITION] of her right foot (inflammation and infection of the skin). In an interview on March 7, 2011, at 11:48 AM, the resident's responsible party said that as a result of this wound and infection, the resident had had to have her leg amputated above the knee. There was a lack of evidence to support that staff adequately monitored the skin integrity of the Resident R53's right foot. There was a lack of evidence that staff identified the wound on the resident's right lateral ankle in a timely manner and as a result, treatment of [REDACTED]. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.10(d) Resident Care Policies. 28 Pa. Code 211.12(d)(5) Nursing Services. Previously cited 7/15/10