Every finding on record at Lafayette-Redeemer, The

Based on observations, review of clinical record and interview with staff, it was determined that facility did not ensure to administer medication according to physician's order for one of 18 residents reviewed (Resident R98)Review of facility policy 'Pharmacy - Medication Administration,' effective date April 9, 2024, indicates its purpose is to ensure safe administration of medication in accordance with regulatory requirements.Review of Resident R98 clinical record revealed medical diagnosis of high blood pressure.Review of R98's physician's orders revealed an active order placed on January 27, 2026 for metoprolol succinate extended release (ER) oral tablet 24 hour 25 mg, to give one tablet by mouth every 12 hours for hypertension (HTN) DO NOT CRUSH.Further review of R98's clinical record revealed a physician order placed on January 27, 2026 indicating may crush medications unless otherwise specified.During medication administration observation on Thursday, January 29, 2026 at 9:20 am, licensed nurse, employee E1, crushed and administered metoprolol 25 mg to R98.Findings confirmed with facility's administrator and director of nursing on Friday, January 30, 2026 at 2:00 pm.28 Pa Code 211.12(d)(1)(5) Nursing services

Based on observations, review of policy, and review of clinical record, it was determined that facility did not ensure to implement enhanced barrier precautions (EBP) for one of 18 residents reviewed. (Resident R98)Review of facility policy 'Isolation Precautions Guidelines,' effective date June 29, 2022, indicates that high contact residents care activities requiring gown and glove use for EBP include: providing hygiene, changing linens, device care or use: central line, urinary catheter, feeding tube, tracheostomy.Review of Resident R98's clinical record revealed an order placed on January 29, 2026, for foley catheter reason: place 16 Fr Foley in for urinary retention.Observation of Resident R98 in room [ROOM NUMBER]-A on Thursday, January 29, 2026, at 9:30 am revealed a nurse aide, employee E4, providing foley care without a gown.Further observations revealed a door posting notification for R98 in room [ROOM NUMBER]-A for EBP.Further observations revealed no evidence of personal protective equipment (PPE) cart near room [ROOM NUMBER]-A.Findings confirmed with facility's administrator and director of nursing.28 Pa Code 211.10(d) Resident care policies

Based on observations and interviews with staff, it was determined that the facility failed to promote care for residents that maintains or enhances dignity and respect related to dining for one of two dining rooms observed (Second floor dining room). Findings include: Observations of the Seceond floor dining room revealed that Resident R2 was falling asleep at the dining table. Licensed Practical Nurse, Employee E4, shouted across tables, R2, you better wake up or I'll have to come over there and feed you like a baby! Follow-up observations of lunch dining in the second-floor dining room, on April 10, 2024, at 12:00 p.m. revealed the following: A table with four residents seated; one resident was served a meal at 12:00 p.m.; two residents were served at 12:22 p.m.; another resident was served at 12:34 p.m. A table of two residents seated; one resident was served a meal at 12:11 p.m. and the other resident was served at 12:21 p.m. Observations at 12:10 p.m. revealed a nurse aide, Employee E5, was assisting Resident R10 with her meal, while standing up. Interview with Employee E5 confirmed that she should have been seated while feeding the resident. 28 Pa. Code 201.29(d) Resident Rights

Based on and review of facility policy, observation and staff interview, it was determined that the facility failed to ensure that all drugs are biologicals were stored and labeled in accordance with professional standards for one of four medication rooms observed. Findings include: Review of facility policy on drug storage reveal that under the section policy, medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal and recording in the facility in accordance with federal, state and other applicable laws and regulations. Under section Procedures, A. the Director of Nursing and collaboration with the consultant pharmacist maintains the facilities compliance with federal and state laws and regulations in the handling of controlled substances. Only authorized license nursing and pharmacy personnel have access to controlled substance. B. Schedule ll to lV medications and other medications subject to abuse or diversion are stored in a permanently affixed, double locked compartment separate from all other medications or per state regulation. Alternatively, in a unit dose system, medication may be kept with other medications in the cart if the supply of medication is minimal and the shortage is readily detectable. The access system to the compartment is different from the key that opens the medication cart. If a key system is used the medication nurse on duty maintains possession of the key to control substance storage areas. Backup keys to all medication storage areas, including those for controlled substances, are kept by the director of nursing or designee. C. Controlled substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator. Observation of the second-floor medication room conducted on April 10, 2024, at 10:39 a.m. together with Licensed Nurse, Employee E6 revealed that a narcotic refrigerator was inside the medication room. Further, observation revealed that the narcotic refrigerator had a lock. However further inspection revealed that the refrigerator was not locked and can be opened without the use of a key. Interview with Employee E6 conducted at the time of the observation confirmed that the narcotic refrigerator was inside the medication room was not locked. Observation of the contents of the narcotic refrigerator revealed that a locked plastic see-through narcotic box containing two boxes of Ativan liquid and a dark colored plastic. Further, observation of the narcotic box revealed that it was not affixed to the refrigerator. Inspection of the contents of the narcotic box revealed two boxes of Ativan liquid and a dark colored plastic bag filled with 7 syringes labelled Ativan 0.5 mg/0.5 ml Inspection of the contents of the box together with the DON (Director of Nursing) Employee E2 and Employee E6 revealed box#1 labelled with Resident R3's name containing an opened but full vial of 5 ml liquid oral lorazepam 2 mg/ml full, box#2 labelled with Resident R3's name containing an unopened bottle of 5 ml liquid oral Lorazepam 2 mg/ml. Further the narcotic box also contained one dark colored plastic bag labelled with Resident R159's name containing seven prefilled syringes containing Ativan 0.5 ml of liquid. review of labels affixed to the syringes revealed the following: lorazepam 0 .5 mg/0.5 ml. Interview with the DON, Employee E2 conducted at the time of the observation confirmed that the narcotic refrigerator was not locked, further Employee E2 also confirmed that the box containing two bottles of liquid oral Ativan and seven prefilled syringes with 0.5 ml of Ativan was not permanently affixed to the refrigerator. Employee E2 stated that she will immediately have engineering attached the box to the refrigerator. 28 Pa. Code 201.18(b)(l) Management 28 Pa. Code 211.12(d) Nursing Services 28 Pa. Code 211.9 (i) Pharmacy Services

Based on review of clinical records, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that one of 19 was free of accidents related to a transfer into a shower chair. (Resident CL209). Findings include: A review of clinical record for Resident R209 revealed that the resident was admitted to the facility on [DATE], with diagnoses including abnormalities of gait and mobility (deviation from normal walking), muscle weakness, need for assistance with personal care, and history of falling. Review of facility investigation dated, September 29, 2023, revealed that Resident CL209 bumped her leg on the shower chair and sustained a tear to the right lower leg during transfer from bed to shower chair which resulted in 14 stitches. Review of a statement, dated September 29, 2023, by unknown staff, revealed that Resident CL209 was being transferred by two staff: was transferring her with my teammate, I saw blood running down her leg . Further review revealed a statement by a student, dated 9/29, which stated that the two employees were transferring a patient and the patient's foot got stuck under the shower chair. And her foot started to bleed. Further review of staff statements failed to reveal information regarding how the transfer was initiated and performed, by the two nurse aides in order to determined if the resident was transfer from bed to the shower chair safely. Interview with the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, conducted on April 11, 2024, at 12:50 p.m. Employee E1 stated that the reenactment of the incident with the staff took place in the shower room, not in Resident CL209's room, where the original transfer occurred. Further, during interview it was stated that the shower chair was removed from use for safety checks. There was no documentation to confirm that the shower chair was inspected for safety. 28 Pa Code 211.10(c) Patient care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of facility policy, observation, clinical record review and interview with staff and residents, it was determined that the facility did not develop comprehensive care plans related to hearing loss, non-compliance with care, and transmission-based precautions for three of 16 records reviewed (Residents R5, R22, R26). Findings include: Review of facility policy titled Comprehensive Plan of Care, dated March 6, 2023, revealed that the plan of care is continually reviewed and updated .to reflect the current needs of the resident, and the interdisciplinary team identifies and prioritizes resident care needs based on analysis of assessment data. Interview with Resident R5 on June 20, 2023, at 11:23 a.m. revealed that the resident has significant hearing loss, which required hearing aids and/or those to whom he has talked to raise their voice in order for them to be heard by the resident. Review of Resident R5's most recent MDS (Minimum Data Set, a periodic assessment of resident care needs), section B, Hearing, Speech, and Vision, completed on April 18, 2023, revealed that the resident utilized a hearing aid in order to understand others adequately. Review of the care plan for the resident revealed no care plan had been developed for his hearing loss as of June 21, 2023. Interview with the Director of Nursing, on June 21, 20233 at 9:50 a.m. confirmed that Resident R5 had hearing loss which had the potential to impact how he communicates and should have had a care plan developed for such. Review of Resident R22's MDS dated [DATE], revealed the resident had cognitive impairment and had diagnoses of dementia (disease that affects the brain's ability to think, remember, and function normally) and muscle weakness. Review of Resident R22's care plan revised May 30, 2023, revealed the resident was at risk for skin breakdown related to impaired mobility with history of skin tear to the plan of her right hand. Interventions dated July 14, 2022, included to encourage resident to keep gauze in right hand due to contracture (permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen). Review of Resident R22's physician orders revealed an order dated August 4, 2022, to apply rolled gauze to the plan of right hand daily. Observations on June 20, 2023, at 11:14 a.m. revealed Resident R22 had a right-hand contracture. Resident R22 was observed to be making a fist with her right hand and was unable to open her hand when asked. Further observations revealed no rolled gauze was in the resident's right hand. Follow-up observations on June 21, 2023, at 9:15 a.m. again revealed Resident R22's right hand in a closed fits and no rolled gauze in her hand. Interview and observations on June 21, 2023, at 9:20 p.m. with Licensed Nurse, Employee E5, confirmed Resident R22 did not have rolled gauze in the right hand. Interview with Licensed Nurse, Employee E5, revealed Resident R22 does not allow staff to put anything in her hand for contracture and that the resident rips everything out that is put in the hand. Observations confirmed Resident R22 became upset when Licensed Nurse, Employee E5, attempted to open the resident's hand. Resident R22 denied any pain. Review of Resident R22's comprehensive care plan revealed no documented evidence a person-centered comprehensive care plan was developed related to the right-hand contracture and non-compliance of treatment. Interview on June 21, 2023, at 9:45 a.m. with the Director of Nursing and Assistant Director of Nursing, Employee E2, confirmed Resident R22 was non-compliant with care of right-hand contracture. Observations on June 20, 2023, at 11:00 a.m. revealed transmission-based precautions signage on the door of 209 with protective personal equipment set up outside the door. Interview on June 21, 2023, at 9:30 a.m. with Licensed Nurse, Employee E5, revealed Resident R26 was on enhanced barrier cautions (require gown and glove during high contact resident care activities). Review of Resident R26's comprehensive care plan revealed no documented evidence a care plan was developed for enhanced barrier precautions or why the resident required enhanced barrier precautions. Interview on June 22, 2023, at 12:42 p.m. with the Director of Nursing, confirmed Resident R26 was on enhanced barrier precautions for colonized MDRO (multidrug-resistant organisms) Klebsiella (type of bacteria that can cause infections that become resistant to antibiotics). Further interview with the Director of Nursing, confirmed no comprehensive care plan was developed. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services

Based on review of clinical record, review of facility documentation, review of facility policy and interviews with staff, it was determined that the facility failed to test the temperature of a hot water beverage provided to one of 13 residents reviewed (Resident R4). This failure resulted in actual harm to Resident R4 who spilled the hot water beverage on his thigh resulting in a first-degree burn. This deficiency was identified as past non-compliance. Findings include: Review of facility policy Hot Beverage Service in Senior Dining revealed hot beverages will be served at a temperature no greater than 170 degrees Fahrenheit (F). Upon completion of brewing hot beverages, allow to cool to a temperature of 170 degrees Fahrenheit. Once the temperature has reached 170 degrees F or less, the hot beverage can be served. Review of Resident R4's Annual MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated March 9, 2022, revealed the resident was admitted to the facility on [DATE], with diagnoses of muscle weakness, arthritis (inflammation of joints causing pain and stiffness), dysphagia (swallowing difficulty), and dementia (loss of cognitive functioning). Continued review of the MDS assessment revealed that the resident was not cognitively intact and required limited assistance for eating with the assistance of one staff person. Review of facility reported documentation indicated that on March 17, 2022, at 6:00 p.m. Resident R4 spilled tea on self. Continued review of facility documentation revealed that hot beverages were brewed at a temperature of 190 degrees Fahrenheit in the main kitchen, the hot beverages then sat on room temperature for an unspecified amount of time, and then got poured into carafe and sent up to the units. Review of facility documentation revealed a written statement by Licensed nurse, Employee E3 that on March 17, 2022, she was made aware by Resident R4's nursing assistant that the resident had spilled a cup of hot tea on his pants. Licensed nurse, Employee E3 promptly assessed the area which revealed a pink area on Resident R4's right upper thigh and a small portion of skin peeled back. Review of Resident R4's skin and wound evaluation dated March 17, 2022, revealed the resident sustained a blister that measured 1.6 cm x 1.8 cm. Continued review of evaluation revealed wound pain was assessed and the resident showed signs of facial grimacing and body language appeared rigid (fists clenched, knees pulled up, pushing or pulling away). Review of Resident R4's clinical record revealed the physician was made aware of the burn on March 17, 2022, and recommended new treatment orders to apply [MEDICATION(S)] to resident's right thigh, twice a day, for seven days. Interview with the Nursing Home Administrator and the Director of Nursing on August 10, 2022, at 3:00 p.m. revealed that food temperatures were being checked before service, however, hot beverage temperatures were not being monitored. Continued interview confirmed the hot beverage temperatures were not checked on March 17, 2022, after brewing and before serving to the residents to ensure safe serving temperatures. On March 17, 2022, following the incident, the facility immediately implemented the following corrective actions: -Resident R4 was immediately removed from dining room following the spill and skin assessment was completed. -The physician was made aware and treatment orders were initiated March 17, 2022. - Rehabilitation screening was initiated March 17, 2022, for Resident R4 to be treated and evaluated by therapy for safety with hot beverages. -Resident R4's care plan was updated March 18, 2022, with new interventions to monitor during meals and provide cueing and assistance with handling of hot beverages. -Dietary staff will keep and maintain kitchen temperature log, initiated March 18, 2022, for hot beverages when they leave the kitchen and log at the point of service on the unit and maintain logs in the dietary office. -Education initiated March 18, 2022, and completed April 3, 2022, for all nursing staff on serving residents and lids on hot liquids in the dining room. -Education initiated March 23, 2022, and completed April 21, 2022, for all dietary staff regarding new standards for hot beverage preparation and distribution. The coffee machine will stay calibrated at a brew temperature of 160 degrees Fahrenheit +/- 5 degrees. -Facility dining service policy was revised March 31, 2022, that hot beverages will be served at a temperature no greater than 150 degrees Fahrenheit +/- 5 degrees. Interviews with nursing and dietary staff on August 10, 2022, confirmed that they had all been in-serviced on policy and procedures regarding serving residents hot liquids in the dining room and checking hot beverage temperatures at point of service. This deficiency was identified as past non-compliance. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on review of closed clinical records, review of facility policy and clinical documentation, it determined that the facility failed to develop a baseline care plan related to diuretic therapy for one of three closed clinical records reviewed (Resident R50). Findings Include: Review of facility policy Baseline Care Plan Guidelines revealed a baseline care plan will be completed and implemented within 48 hours of a resident's admission in order to promote continuity of care and communication among staff, and increased safety. Key elements of a baseline care plan include physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan will reflect the resident's goals and provide interventions that address current needs. Review of Resident R50's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R50's admission summary dated June 1, 2022, revealed the resident had [CONDITION(S)] (swelling caused by excess fluid trapped in the body's tissues) to his bilateral lower extremities. Review of Resident R50's June 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] & swelling) one time per day for diuresis (increased or excessive production of urine). Review of Resident R50's clinical record revealed documentation dated June 8, 2022, by the Physician, Employee E6, that the resident was seen for leg swelling and made recommendations to adjust the resident's diuretic medication. Review of Resident R50's discharge summary dated June 15, 2022, by Employee E6, revealed the resident was noted with increased [CONDITION(S)] in legs, was unresponsive to baseline diuretics, and was noted with urinary retention. Resident R50 was subsequently transferred to the hospital. Review of Resident R50's baseline care plan revealed no care plan was developed related to the resident's diuretic therapy. 28 Pa. Code 211.11 (d) Resident care plan 28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record review, review of facility policies and documentation and interviews with staff, it was determined that the facility failed to provide adequate supervision while transferring a resident which resulted in a fall, for one of five residents reviewed for falls (Resident R21). Findings include: Review of facility policy, Mechanical Sling Lift dated last revised March 13, 2014, revealed that a resident's individualized plan of care must be followed while moving or transferring a resident. Continued review revealed that, two persons . must be present at all times during set-up or transfer. Review of Resident R21's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated January 17, 2020, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including cancer, heart failure, kidney disease, dementia (progressive disorder of the brain resulting in memory loss, confusion and impaired judgement), chronic lung disease and muscle weakness. Continued review of the clinical record revealed that the Resident R21 was totally dependent on two or more staff persons for transfers, that she was frequently incontinent of urine and always incontinent of bowel. Review of Resident R21's care plan dated initiated September 15, 2017, revealed that the resident had a deficit related to activities of daily living and mobility. An intervention, dated May 15, 2019, revealed that the resident required a mechanical hoyer lift and assist of two staff persons for transfers. Review of progress notes revealed a note dated March 21, 2020, at 6:45 p.m. which indicated that a nurse aide was transferring Resident R21 with a stand lift from her wheelchair to her bed. The resident was sitting on the edge of her bed, slid out of the sling and slid to the floor with her back against the bed. The resident was assisted back to bed with a hoyer lift and two staff members. Review of facility documentation related to the above incident revealed a written statement from the nurse aide, Employee E5, which indicated that the employee went to assist Resident R21 to get cleaned up after having a bowel movement. Employee E5 stated that Resident R21 is a hoyer lift but I used the stand device, I didn't wait for my coworker and tried to clean her up. I went ahead before my coworker got there to assist me and removing her from the chair to the bed and [Resident R21] slid down from the edge of the bed with feces splattered over the bed and floor and I lowered her down to the floor myself and went and got the team leader while my coworker stayed with [Resident R21]. Review of Employee E5's personnel file revealed that the employee was hired by the facility July 1, 2019. On July 2, 2019, Employee E5 received skills competency training related to safe handling of residents which included education that The use of a lift requires two people. Under no circumstances is anyone allowed to use a lift by themselves. A two person transfer with the lift includes but is not limited to: the beginning set up, the transfer process . and movement until the transfer is completed. Employee E5 received additional skills training related to use of mechanical lifts on November 25, 2019, during an annual competency review. Interview on August 3, 2021, at 10:00 a.m. the Nursing Home Administrator confirmed that Employee E5 had received education and skills competencies regarding the proper use of lifts and that Employee E5 failed to properly transfer Resident R21 which resulted in a fall. 28 Pa Code 211.12(d)(5) Nursing services

Based on review of facility policy and procedures, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices related to the use of appropriate personal protective equipment for one of two resident rooms on transmission-based isolation precautions. (Resident R1) Findings include: Review of faculty policy titled Isolation Precautions Guidelines, dated June 10, 2016, revealed Airborne Precautions-Patient or resident will be asked to a mask at all times until transferred. The staff will wear a surgical mask when caring for the patient. Contact Precautions and [MEDICATION(S)] Contact Precautions- Personal protective equipment to be worn by healthcare workers for contact precautions and [MEDICATION(S)] contact precautions- a. Gown and gloves for all interactions that may involve contact with patient or potentially contaminated areas in the patient environment. b. Don the gown and gloves upon room entry and discard before exiting the patient's room. Review of progress note for Resident R1 dated July 29, 2021, revealed that the resident was on observation due to her roommate presented with a fever. Interview with the nursing home administrator on August 2, 2021 at 11:30 a.m. stated Resident R1 was placed on transmission based precautions for COVID-19 surveillance and anyone entering the room should wear a N-95 respirator(a particulate-filtering facepiece respirator that meets the U.S. National Institute for Occupational Safety and Health N95 classification of air filtration, meaning that it filters at least 95% of airborne particles.), face-shield or goggles, gown and gloves. Observation of the Resident R1's room [ROOM NUMBER] on August 2, 2021, at 12:45 p.m. revealed a Stop sign posted outside the resident room alerting the staff about airborne and contact isolation precautions. The sign indicated that the staff should wear an N-95 mask, goggles, gown and gloves before entering the resident room. Further observation of Resident R1's room [ROOM NUMBER] revealed that Employee E4, Occupation Therapy Assistant, was standing inside the resident room close to Resident R1. Employee E4 was wearing a surgical mask. It was also observed that Employee E4 did not wear gown, gloves, goggles or face-shield and an N-95 respirator as required while inside the resident room. Interview with the Unit Manager, Employee E3, confirmed that Employee E4 should have been wearing an N-95 respirator, goggles or face-shield, gown and gloves as required before entering Resident R1's room. Pa. Code 201.14(a) Responsibility of licensee

Based on closed clinical record review and interviews with staff, it was determined that the facility failed to obtain laboratory studies as ordered by physician for one of four closed records reviewed. (Resident RCL1) Findings include: Review of Resident RCL1's closed clinical record revealed a nursing progress note, dated April 17, 2020 at 11:20 a.m., Resident is Covid-19 positive. Denies pain, cough, SOB (shortness of breath). Afebrile (without fever) this shift. Resident has very poor appetite, tolerating very little fluids, and refuses to get out of bed. [Physician] made aware and a STAT (urgent/immediate) CBC (complete blood count is a blood test used to evaluate overall health and detect a wide range of disorders) and BMP (basic metabolic panel is a blood test consisting of eight biochemical tests which provide information about the body's fluid balance, levels of electrolytes and how well the kidneys are working) is put in. Call [Physician] with results. Further review of Resident RCL1's closed clinical record revealed no evidence that the CBC and BMP lab tests was completed on April 17, 2020. Interview on December 18, 2020 at 1:00 p.m. with Director of Nursing confirmed that the above laboratory studies were completed as ordered by physician. The Director of Nursing stated, The order for lab studies was not entered into the electronic system until 15:11 (3:11 p.m.). Entering the order is a function of our unit clerk. The unit clerk is no longer employed at this facility. Employee E2 further stated, that the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In this case, the lab studies were not completed. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d) Nursing services 28 Pa. Code 211.12(5) Nursing services

Based on review of facility policy, clinical records and staff interviews, it was determine that the facility failed to provide the right to formulate Advance Directives (written instructions such as a living will or durable power of attorney for healthcare when the individual is incapacitated) for nine of nine records reviewed (Residents R13, R63, R72, R35, R316, R6, R10, R18, and R88). Findings include: Review of facility policy Advance Directives Guidelines, dated revised on (MONTH) 26, (YEAR), revealed: . VIII. Procedure: . 4. At time of admission, the Resident/ Patient or designated legal party will indicate, by signature, if an Advance Directive exists. 5. If an Advance Directive exists, it is to be made a part of the permanent medical record. 6. If an Advance Directive does not exist, a copy of information regarding Patient Self Determination Act will be provided to the Resident/Patient or designated legal party. 7. As part of the Nursing Admission process, the Resident/Patient will again be asked about an Advance Directive and requested to supply if this has not been done previously. 8. The Attending Physician will review the Advance Directive during the Admission Assessment and write appropriate orders to assure execution of the Directives. 9. The Social Service Department will be used as a resource for information and assist in executing an Advance Directive, if requested. They will provide follow up to initial request within 72 hours for Advance Directive if Resident/POA still has not provided a copy. 10. A copy of the Advance Directive will be placed at the front of the Resident's/ Patient's chart. 11. Annually, the Interdisciplinary Team will review each Resident's/Patient's Advance Directive in conjunction with Resident/ Patient/ POA to ensure it is current. Review of Resident R13's clinical record revealed that the resident was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Continued review of the resident's clinical record revealed that there was no advanced directive or code status information entered in the clinical record or electronic health record. This was confirmed by Employee E4, the Social Service Coordinator on (MONTH) 7, 2019 at 9:47 AM. Review of Resident R63's clinical record revealed the resident was admitted to the facility on (MONTH) 12, (YEAR), with diagnoses, including but not limited to, hypertension (elevated blood pressure), [MEDICAL CONDITION] (poor circulation of the extremities) and [MEDICAL CONDITION] embolism (condition in which one or more arteries in the lungs become blocked by a blood clot). Continued review of the clinical record revealed that the resident's code status listed on the (MONTH) 12, 2019, readmission orders [REDACTED]. Review of April's physician's orders revealed no order for the resident's code status. Continued review of the clinical record revealed no defined code status listed in the physician's notes or the resident's care plan. On (MONTH) 10, 2019, a care conference was held and the resident's representatives were present at the meeting. There was no documentation that the resident's code status was not addressed with the family or that information on Advanced Directives was offered to the family. This was confirmed by Employee E4 on (MONTH) 7, 2019 at 9:32 AM. Review of the clinical record for Resident R72 revealed that the resident was admitted to facility on (MONTH) 25, (YEAR) with [DIAGNOSES REDACTED]. Continued review of the clinical record revealed that the resident was hospitalized from (MONTH) 5 to (MONTH) 10, 2019 for respiratory distress. Review of Resident R72's physician's orders dated (MONTH) 2019 revealed no physician order for [REDACTED]. Interview with Employee E4, Social services Coordinator on (MONTH) 7, 2019 at 9:32 AM revealed that Advance Directives/Code Status are not entered in the electronic health record; Advance Directive information is provided by social services only when requested and that social service review the code status once a year. Employee E4 further indicated that she has not documented that review lately. A review of the clinical record for Resident R35 revealed that the resident was admitted to the facility on (MONTH) 8, (YEAR), with diagnoses, including but not limited to, arthritis due to other bacteria (Inflammation of one or more joints, causing pain and stiffness), Type two Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar), presence of an artificial knee joint, and severe obesity. Further review of the clinical record for Resident R35 revealed physician progress notes [REDACTED]. Continued review of the clinical record revealed no documentation of a completed advance directive from the resident. Interview on (MONTH) 6, 2019, at 2:25 p.m., Employee E17, charge nurse, confirmed that Resident R35's clinical record did not include documentation of the resident's wishes regarding CPR or an Advance Directive. A review of the clinical record for Resident R316 revealed that the resident was initially admitted to the facility on (MONTH) 9, (YEAR), and again on (MONTH) 8, 2019. [DIAGNOSES REDACTED]. Further review of the clinical record for Resident R316 revealed an Admission Agreement dated (MONTH) 8, 2019, which was not signed by the Resident or Power of Attorney. Documentation in the clinical record did not include an advance directive from the resident or discussions of the resident's right to formulate an Advance Directive. Interview with Employee E18, charge nurse, on (MONTH) 6, 2019, at 2:25 p.m., confirmed that Resident R316's clinical record did not include documentation of the resident's wishes regarding CPR or an Advance Directive. A review of the clinical record for Resident R6, revealed a physician order dated (MONTH) 1, 2019, which indicated Resident R6 was a Do Not Resuscitate, (DNR), if breathing and/or heart would stop. Continued review of R6's clinical record revealed no documentation indicating that Resident R6 wished to be DNR. A review of the clinical record for Resident R10 revealed a physician order dated, (MONTH) 1, 2019, which indicated Resident R10 was a Do Not Resuscitate, (DNR), if breathing and/or heart would stop. Continued review of R10's clinical record revealed no documentation indicating that Resident R10 wished to be DNR. A review of the clinical record for Resident R18 revealed a physician order dated (MONTH) 1, 2019, which indicated Resident R18, was a Do Not Resuscitate, (DNR), if breathing and/or heart would stop. Continued review of Resident R18's clinical record revealed no documentation indicating that Resident R18, wished to be DNR. A review of the clinical record for Resident R88 revealed a physician order dated (MONTH) 1, 2019, which indicated Resident R88 was a Do Not Resuscitate, (DNR), Do Not Intubate, (DNI - do not want any assisted breathing device placed) and Do Not Hospitalize, (DNH), if breathing and/or heart would stop. Continued review of R88's clinical record revealed no documentation indicating that Resident R88 wished to be DNR. Interview with Employee E2, licensed nurse on (MONTH) 7, 2019, at 11:45 a.m. confirmed that Resident's R6, R10, R18 and R88, had no documentation to confirm and/or indicate that physician order's related to code status wishes accurately reflected the wishes of the resident and/or family/guardian as required. The facility failed to provide the right to formulate Advance Directives to nine residents as required. 28 Pa. Code 201.18(b)(1) Management Previously cited [DATE], [DATE] and [DATE]. 28 Pa. Code 201.29(i) Resident rights 28 Pa. Code 211.5(f) Clinical records Previously cited [DATE], [DATE] and [DATE]. 28 Pa. Code 211.12(d)(1) Nursing services Previously cited [DATE], [DATE] and [DATE]. 28 Pa. Code 211.12(d)(5) Nursing services Previously cited [DATE], [DATE] and [DATE].

Based on observations and interviews with staff, it was determined that the facility failed to promote resident dignity during dining for one of two dining rooms (second floor) and during a personal phone call for one of one resident observed (Resident R32). Findings include: An observation of Resident R32 completed on (MONTH) 2, 2019, at 10:55 a.m., revealed the resident having a personal phone conversation with a family member at the nurses station of the second floor nursing unit. Interview with Employee E10, licensed nurse, at the time of the observation, revealed that the facility does not have a cordless phone available resident use. Employee E10 further indicated that R32's dignity was not enhanced during the phone conversation. Observation of the Second Floor lunch meal on (MONTH) 02, 2019, at 12:08 p.m., revealed that staff served lunch to four of the five residents seated at a table at the same time. Resident R7, was also seated at the same table did not got served until 12:20 p.m Interview with Employee E9, certified nursing assistant, on (MONTH) 2, 2019, at approximately 12:43 p.m. revealed that lunch trays arrived onto the unit at different times. Review of Resident R7's quaterly Minimum Data Set, (MDS - periodic assessment of needs) dated, (MONTH) 2, 2019, revealed that Resident R7 was one person assist during meals. Interview with Employee E11, certified nursing assistant, on (MONTH) 2, 2019 at approximately 12:51 P.M confirmed the finding. Further observation of the lunch meal on (MONTH) 2, 2019, between 12:15 - 1:30 p.m. of the residents in the second floor main dining room revealed that Resident's R113, R103, R44 and R42, were still not given lunch meals, while approximinatley 12 other resident's in the dining room, had eaten lunch and their plates were being cleared away. During the observation an interview was done with three certified nurse aides, Employee's E7, E12 and E13, that were assigned to assist with dining services, it was revealed by each of them, Resident trays do not come up from dietary on the same carts. Resident's R113, R103, R44 and R42, were sitting at a table with Resident's R6, who was not given her lunch meal till after R113, R103, R44 and R42, had finished there lunch. A second lunch observation of the second floor dining room on (MONTH) 6, 2019, at 12:55 p.m. revealed the same identical situation for Resident's R113, R103, R44, R42 and R6, as it occurred on (MONTH) 2, 2019. Interview with Employee E2, licensed nurse on (MONTH) 6, 2019, at 1:15 p.m. confirmed the observation and indicated that each Resident's diginity was not being enhanced during the dining experience. An additional observation of Resident R6, on (MONTH) 6, 2019, at 12:15 p.m. revealed that she was wearing an adult protective device, (to keep food spillage from going onto personal clothing), closer observation of the protective device, revealed that it had dried on bite sizes pieces of blueberry pancake and was heavily soiled with a brown substance around the neck of the protective device. The facility failed to ensure resident's dignity was enhanced during a phone conversation and during dining. 42 CFR 483.10(a) Resident rights. Previously cited state deficiency 8/8/18. 28 Pa. Code 201.29 (j) Resident rights. Previously cited 8/8/18, 12/18/18 and 7/13/17.

Based on observation and resident and staff interviews, it was determined that the facility failed to have signage to direct the residents to the location of the State Agency survey results and failed to have the results readily accessible for review on two of two nursing units reviewed (2nd and 3rd floor nursing units). Findings include: Group interview on (MONTH) 3, 2019 at 11:00 a.m. with a group of four alert and oriented (as identified by a facility employee) Resident Council residents who provided representation from both clinical nursing units revealed that all four residents did not know where the State Agency survey results were situated in the facility. Observation on (MONTH) 6, 2019 at 12:10 p.m. revealed the State Agency survey results were not posted on the first-floor and second-floor clinical nursing units where they were readily accessible for review. Interview on (MONTH) 7, 2019, at 1:00 p.m. with the Director of Nursing revealed confirmation that the State Agency survey results were not accessible to residents. The facility failed to have signage to direct the residents to the location of the State Agency survey results and failed to have the results readily accessible for review. 28 Pa. Code: 201.13(g) Issuance of license 28 Pa. Code 201.18(a) Management Previously cited 8/8/18, 12/18/18 and 7/13/17. 28 Pa. Code 201.18(b) Management Previously cited 8/8/18, 12/18/18 and 7/13/17. 28 Pa. Code 201.18(e)(1) Management Previously cited 8/8/18, 12/18/18 and 7/13/17. 28 Pa. Code 201.29(a) Resident rights Previously cited 8/8/18, 12/18/18 and 7/13/17.

Based on a review of facility policy and interviews with residents and staff, it was determined that the facility failed to ensure that residents were notified of the procedure for filing a grievance and the procedure to file anonymously with the facility for four of 37 residents reviewed ((Residents R1, R9, R40, and R99). Findings include: Review of facility policy titled, Grievance/Complaint Policy, dated effective (MONTH) 30, 2019, revealed that a concern may be filed verbally or in writing, and the reporter my request to remain anonymous. During the group interview on (MONTH) 3, 2019, at 11:00 a.m. with four residents identified by the facility as being alert and oriented (Residents R1, R9, R40, and R99) it was stated by all four residents that they did not know how to file a grievance and/or a concern and how they would file anonymously. Observation of both nursing unit on the second and third floor on (MONTH) 6, 2019, at approximately 10:00 a. m. there was no Grievance/Concern forms available to residents and/or family members to file a grievance anonymously. Interview with the Nursing Home Administrator on (MONTH) 7, 2019 at 11:10 a.m. confirmed that the facility did not have Grievance/Concern forms available to residents and/or family members to file a grievance anonymously. The facility failed to ensure that four residents were provided with information on how to file a grievance. 28. Pa Code 201.18 (e) (4) Management. Previously cited 8/8/18, 12/18/18 and 7/13/17.

Based on review of clinical documentation and interviews with resident and staff, it was determined that the facility failed to revise resident care plans in a timely manner for one of 37 resident records reviewed (Resident R93). Findings include: Review of Resident R93's clinical record revealed an admitted (MONTH) 10, (YEAR) with a diagnose of Parkinson Disease (caused by a loss of nerve cells in the brain, symptoms include tremors, shaking, stiffness, and movement problems). Review of Resident R93's Physical Therapy evaluation dated, (MONTH) 24, 2019 indicated the resident has had a functional deficit related to transfers, ambulation and wheelchair mobility due to a risk for falls, decreased participation in functional tasks and increased dependency on caregivers. Interview with Resident R93 on (MONTH) 2, 2019 at, 11:00 a.m., revealed that the resident indicated the symptoms of her [MEDICAL CONDITION] has gotten worse. The resident stated, I have fallen three times in the past month. (Review of the clinical records revealed Resident R93 fell on (MONTH) 10, 14, 23, 2019). I should use the call bell when I need help from the staff but I was so use to doing things for myself I don't. I haven't used my walker since the falls, I only use the wheelchair because I get so dizzy. I just can't do the things I could do before. I was also told I should be supervised in the bathroom because I might fall. I've started Physical Therapy again to help me use the wheelchair. Further review of Resident R93's clinical records revealed a care plan for Activities of Daily Living (ADL), self-care performance and mobility, with interventions that included: Bathroom safety the patient can be left alone in the bathroom and does not need direct supervision and knows how to use the call light for assistance Rolling walker needed for ambulation . Resident request to keep wheelchair out of room since she is not using it. Interview with the Director of Nursing on (MONTH) 3, 2019 at 2:00 p.m., confirmed that Resident R93's care plan was not updated since her change in condition and the facility failed to update and revise the care plan to identify the resident's recent decline in ADL. The facility failed to revise one resident's care plan following a decline in the resident's physical condition. 28 Pa. Code 211.10(b)(c) Resident care policies 28 Pa. Code 211.11 (b)(c) Resident care plan 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 8/8/18, 12/18/18 and 7/13/17.

Based on review of clinical records and interviews with resident and staff, it was determined that the facility failed to follow physician orders [REDACTED]. Findings include: Review of Resident R20's clinical record revealed [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Nursing documentation revealed daily weights were not obtained as ordered. This was verified with the Director of Nursing on (MONTH) 3, 2019 at 11:00 a.m Review of Resident R93's clinical record revealed an admitted (MONTH) 10, (YEAR) with a [DIAGNOSES REDACTED]. Further review of Resident R93's clinical records revealed a care plan dated (MONTH) 31, (YEAR) related to [MEDICAL CONDITION] affecting gait and balance with interventions that included to give medication as ordered by the physcian. Interview with Resident R93 on (MONTH) 6, 2019 at 12:15 p.m. revealed that she was concerned about not receiving her [MEDICATION NAME] ( medication to treat the symptoms of [MEDICAL CONDITION]) on time . The resident indicated that I feel a difference in myself when its not on time, when it starts wearing off I get shaky. Additionally, she indicated that when she spoke to her Neurologist about this, he specifically stated that this type of medication should be given every four hours at the same time each day. Further review of Resident R93's clinical record revealed that on a previous Neurologist appointment dated (MONTH) (YEAR), the doctor underlined the hours the medication should be taken and wrote, Parkinson medication should be on time and underlined 8 am-12 pm-4 pm-8 pm). Continued interview with Resident R93 on (MONTH) 6, 2019, revealed Today I received my [MEDICATION NAME] over an hour late, I did not get it until 9:15 a.m. Observation during the interview revealed that Employee E19, registered nurse, administered the second dose (12 p.m.) of [MEDICATION NAME] at 1:00 p.m. Interview with the Director of Nursing on (MONTH) 6, 2019 at 3:00 p.m. confirmed that the resident's [MEDICATION NAME] medication should be administered every four hours at the same time every day. The facility failed to follow physician orders [REDACTED]. 42 CFR 483.25 Quality of Care. Previously cited state deficiency 8/8/18 and 7/13/17. 28 Pa. Code: 211.12(d)(3)(5) Nursing services Previously cited 8/8/18, 12/18/18 and 7/13/17.

Based on review of clinical records, facility documentation and staff interviews, it was determined that the facility failed to provide adequate supervision and appropriate assistive devices for one of nine residents reviewed (Resident R10). Findings include: Review of the clinical record for Resident R10 revealed a physician order [REDACTED]. Review of Resident R10's quarterly MDS, (Minimum Data System -periodic assment of resident care needs) dated (MONTH) 2, 2019, indicated that for transfers (how resident moves between surfaces including to or from bed, chair, wheelchair and/or standing position) Resident R10 requires extensive assistance with the physical assistance of two plus staff persons. Further review of Resident R10's clinical record revealed a Morse Fall Scale, (a fall risk assessment that determines ones risk of falling) dated (MONTH) 18, 2019, which revealed that Resident R10 was assessed with [REDACTED]. Continue review of Resident R10's physician orders [REDACTED]. Review of Resident R10's careplan's revealed a careplan titled, ADL-self care, related to mobility deficit, because of limited mobility, which was dated (MONTH) 23, (YEAR), which indicated that R10 was to be transferred via a slide board, (Beasy Board) for going back and forth from bed to wheelchair, with two staff person's present during the use of Beasy Board. Review of nursing progress notes for Resident R10 revealed a note dated (MONTH) 12, 2019, at 1:00 p.m. which indicated Resident was lowered to the floor while transfering from bed to the chair. Residents foot slipped and she lost her balance during transfer. Resident was wearing slippers. Resident uninjured and denies pain. Review of facility documentation, titled, CNA ADL Care Tracking - (documentation signed by a staff person indicating that care was performed as required) for (MONTH) 12, 2019, indicated that Resident R10's transfer from the bed to the wheelchair was not done by using the Beasy Board as required. Interview with the Director of Nursing, Assistant Director of Nursing and Employee E2, licensed nurse, on (MONTH) 7, 2019, at 12:50 p.m. confirmed that on (MONTH) 12, 2019, at 9:15 a.m. Resident R10 was not properly transferred from bed to wheelchair using the Beasy Board causing the staff person to have to lower the resident to the floor. The facility staff failed to provide the appropriate assistive devices (Beasy board) for one resident during a transfer creating an environment that was not free of accident hazards. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited state deficiency 7/13/17. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 201.18(b)(3) Management Previously cited 8/8/18, 12/18/18 and 7/13/17. 28 Pa. Code: 201.18(e)(1) Management 28 Pa. Code: 211.12(c) Nursing services Previously cited 8/8/18, 12/18/18 and 7/13/17. 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 8/8/18, 12/18/18 and 7/13/17.

Based on review of clinical records, facility documentation and facility policy and interviews with staff, it was determined that the facility failed to ensure that residents identified with weight loss received the appropriate level of nutritional support for one of 10 resident's reviewed (Resident R10). Findings include: Review of facility policy titled, Weight Management Guidelines, dated (MONTH) 1, (YEAR), revealed . The dietician will be responsible for reviewing all the weights on a monthly basis . and . The dietician will make recommendations for interventions as appropriate. Lastly review of the facility policy and procedure, indicated, The intent of this review is to avoid, limit, or reduce . slow weight loss or gain over several months. Review of Resident R10's clinical record revealed on (MONTH) 1, (YEAR), the recorded weight for Resident R10 was 147 pounds. On (MONTH) 6, 2019, Resident R10's recorded weight was 132 pounds, which reflected a loss of 15 pounds. Review of nutritional progress notes between (MONTH) 1, (YEAR) - (MONTH) 6, 2019, revealed no nutritional interventions were put in place for Resident R10. Interview with Employee E8, Dietician, on (MONTH) 7, 2019, at 12:10 p.m. confirmed that no nutritional interventions were put in place for Resident R10 from (MONTH) 1, (YEAR) to present to address the documented 15 pound weight loss. Further interview with Employee E8 confirmed that she had not reviewed Resident R10's weights on a monthly basis, as per facility policy. The facility failed to properly monitor one resident identifed with a 15 pound weight loss. 28 Pa. Code: 211.5(f)(h) Clinical records 28 Pa. Code: 211.10(c) Resident care policies 28 Pa. Code: 211.12(d)(1)(3) Nursing services 28 Pa. Code: 211.12(d)(5) Nursing services

Based on review of clinical records and facility policies and interviews with staff, it was determined that the facility failed to provide adequate monitoring for the care and maintenance of intravenous (IV-tube inserted through the skin into a vein to administer fluids and medications) catheters, for one of 37 residents reviewed (Resident R314). Findings include: Review of the clinical record for Resident R314 revealed the resident was admitted to the facility from the hospital on (MONTH) 8, 2019, with [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. Review of facility nursing policy dated (MONTH) 5, (YEAR), Peripherally Inserted Central Catheter (PICC) Line Management, Complications, and Removal guideline revealed that dressings over a PICC line should be changed every seven days and as needed and note the external length of the catheter to evaluate migration (movement from original site). Any noted migration from prior measurement should be reported to the physician. Review of undated facility nursing policy, Central Line Catheter Protocol revealed that the licensed nurse would measure the external length of the catheter (amount of catheter tubing that is visible outside of the vein) on admission, and every seven days (with dressing change) and as needed. It also revealed that the licensed nurse would measure upper arm circumference three inches above insertion site on admission and every seven days and as needed. Review of the Treatment Administration Record (TAR) for Resident R314 revealed no documentation regarding the external length of the catheter and upper arm circumference three inches above insertion site with scheduled dressing changes on (MONTH) 16, (MONTH) 23 and (MONTH) 30, 2019. Interview with Employee E16, charge nurse, on (MONTH) 6, 2019, at approximately 1:12 p.m., confirmed that there was no documentation of the external length of the catheter and upper arm circumference three inches above insertion site for Resident R314's PICC line during three scheduled dressing changes on (MONTH) 16, (MONTH) 23, and (MONTH) 30, 2019. The facility failed to adequately assess and monitor one resident with a PICC line. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services Previously cited 8/8/18, 12/18/18 and 7/13/17. 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 8/8/18, 12/18/18 and 7/13/17. 28 Pa. Code 211.12(d)(2) Nursing services Previously cited 8/8/18, 12/18/18 and 7/13/17.