Every finding on record at Lakeside at Willow Valley

Based on review of facility policy, review of facility documentation, observations, and interview with staff, it was determined that the facility failed to store food and maintain appropriate sanitation in accordance with professional standards for food service safety. Findings included: Review of facility policy, Food Storage, reviewed January 2024, indicated that all food items should be labeled, dated, and rotated to insure FIFO (first in, first out) method of storing and use and to prevent outdated food from being used. Review of facility policy, Sanitation Process, revealed that sanitizer must be mixed at the proper concentration and checked at regular intervals with a test kit and logged on sanitizer log. Sanitizing solutions will be kept in clearly labeled red buckets of sufficient size and quantity to insure effective use. Review of the Three-Compartment Sink, Sink & Surface Cleaner & Sanitizer Concentration Log revealed that the concentration levels (ppm-parts per million) normal range is between [PHONE NUMBER] ppm. Observations on December 2, 2024, at 9:40 a.m. in presence of Employee E3 revealed three bags of pasta, one bag of mixed vegetables, two packages of chicken, and an opened bag containing cookie dough in the walk-in freezer. All had been removed from the shipping box and had no label or date. Observation on December 2, 2024, at 9:50 a.m. in presence of Employee E3 revealed the sanitizer concentration level in a red bucket was 170 ppm. An additional observation of the sanitizing solution received directly from the dispenser at the three-compartment sink revealed a concentration level of 170 ppm. Interview with Employee E3 confirmed that all items should be labeled and dated. Additionally, Employee E3 confirmed that the sanitizer concentration level did not meet the recommended range. 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

Based upon observation it was determined that the facility failed to screen visitors for COVID 19 [CONDITION(S)] symptoms prior to entering the facility for 4 out of 4 days of the survey. Findings include: Observation on February 24, 2022 at 9:00 a.m., February 25, 2022 at 11:00 a.m., February 28, 2022 at 8:30 a.m. and March 1, 2022 at 9:00 a.m. revealed that surveyors entered the facility without prior screening for the COVID 19 virus symptoms. Observation at the reception desk revealed that a sign-in form was provided to visitors. The sign-in form indicated that visitors were to either be screened at the entrance or confirm that the visitor had no signs/symptoms of COVID-19. Interview with the Nursing Home Administrator on February 28, 2022 at 11:00 a.m. revealed that all visitors are to be screened at an outdoor screening located outside the facility at one of the entrance gates. Observation failed to reveal visible signage directing visitors to the screening location; and the electronic gates of the driveway entrance to the skilled nursing building opened when cars approached the gate. Further observation revealed that the screening location was at a different entrance gate with no signage available. Interview with the Nursing Home Administrator revealed that employees at the screening location were not to open the gate without first completing the screening. Observation on March 1, 2022 at approximately 8:30 a.m. at the second entrance revealed COVID virus screening was not performed at that entrance and employees opened the entrance gate without screening the surveyor, first. Further interview with the Nursing Home Administrator on February 28, 2022 confirmed all surveyors were permitted entrance into the facility on each of the survey days without being screened for COVID 19 prior to entrance. The facility failed to screen surveyors for COVID 19 prior to entrance to the facility on all days of the survey. 28 Pa. Code 201.18(b)(1) Management

Based on clinical record review, it was determined that the facility failed to ensure that non-pharmaceutical interventions were attempted prior to the administration of as needed pain medications for four out of four residents reviewed (Resident #9, Resident #32, and Resident #56). Findings include: Review of Resident #9's [DIAGNOSES REDACTED]. Review of Resident #9's physician's orders [REDACTED]. Review of Resident #9's (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Records (MARs) failed to reveal that non-pharmaceutical interventions were attempted prior to the administration of the as needed medication [MEDICATION NAME] on (MONTH) 20, (YEAR) at 12:50 p.m. and (MONTH) 21, (YEAR) at 4:38 p.m. Review of Resident #56's [DIAGNOSES REDACTED]. Review of Resident #56's January, (MONTH) and (MONTH) (YEAR) physician's orders [REDACTED]. Review of Resident #56's (MONTH) (YEAR), (MONTH) (YEAR) Medication Administration Records (MARs) failed to reveal that non-pharmaceutical interventions were attempted prior to the administration of the above stated as need medications as follows: [MEDICATION NAME] 50mg on (MONTH) 7, (YEAR) and (MONTH) 22, (YEAR). [MEDICATION NAME] 50 mg was administered twenty-two times during (MONTH) (YEAR) and [MEDICATION NAME] 5 mg on (MONTH) 1, (YEAR), (MONTH) 3, (YEAR), (MONTH) 5, (YEAR), (MONTH) 7, (YEAR), (MONTH) 19, (YEAR), (MONTH) 25, (YEAR) and (MONTH) 29, (YEAR). Review of (MONTH) (YEAR) MAR indicated [REDACTED]. Further review of Resident #56's (MONTH) (YEAR) MAR indicated [REDACTED]. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 30, (YEAR) at approximately 2:00 p.m. confirmed that non-pharmaceutical interventions were not attempted prior to the administration of the above medications. Resident #32's clinical record revealed an admitted (MONTH) 18, 2010. Review of physician's orders [REDACTED]. Further review of #32's clinical record revealed Medication Administration Record [REDACTED]. Further review of #32's clinical record revealed Medication Administration Record [REDACTED]. An interview was conducted with the Director of Nursing on (MONTH) 30, (YEAR) at 10:13 a.m. confirmed that no pharmacological interventions were not provided for pain medications. 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(c) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on clinical record review, it was determined that the facility failed to ensure that physician's orders were followed and/or clarified with regard to administration of pain medication and failed to accurately assess pain levels prior to the administration of pain medication to determine adequate indications for use for two out of four residents reviewed (Resident #9 and Resident #56). Findings include: Review of Resident #9's [DIAGNOSES REDACTED]. Review of Resident #9's physician orders revealed orders for [MEDICATION NAME](opioid medication used to treat pain) Extended Release 30 milligrams (mg) to be administered one time per day for pain management; [MEDICATION NAME] (narcotic medication used to treat pain) 7.5-300 mg to be administered every 6 hours as needed for moderate to severe pain; and Tylenol (non-narcotic pain medication) 650 mg to be administered two times per day for pain. Review of Resident #9's comprehensive plan of care for pain revealed that observation should occur for effectiveness and side effects of pain medication; monitor/record pain characteristics, Quality, Severity (1 to 10 scale), anatomical location, onset and duration of pain as well as relieving factors. Review of Resident #9's (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Records (MARs) failed to reveal pain scales associated with mild, moderate and/or severe pain for MS Contin, [MEDICATION NAME] and Tylenol to determine the appropriateness of the pain medication prior to administration. Review of Resident #9's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further review of Resident #9's (MONTH) (YEAR) MAR indicated [REDACTED]. Review of Resident #9's (MONTH) (YEAR) MAR indicated [REDACTED]. Further review of Resident #9's (MONTH) (YEAR) and (MONTH) (YEAR) MAR indicated [REDACTED]. Review of Resident #56's [DIAGNOSES REDACTED]. Review of Resident #56's (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Records (MARs) failed to reveal pain scales associated with moderate pain for Tylenol and [MEDICATION NAME], and severe pain for [MEDICATION NAME] to determine the appropriateness of the pain medication prior to administration. Review of Resident #56's January, (MONTH) and (MONTH) (YEAR) physician orders revealed orders for Tylenol 1000 mg to be administered two times per day as needed for moderate pain; [MEDICATION NAME] (narcotic pain medication) 50 mg to be administered every 6 hours as needed for moderate pain and [MEDICATION NAME] (opioid pain medication) 5 mg to be administered every hour as needed for severe pain. Review of Resident #56's (MONTH) (YEAR) MAR indicated [REDACTED]. Further review of Resident #56's (MONTH) (YEAR) MAR indicated [REDACTED]. Further review of Resident #56's (MONTH) (YEAR) MAR indicated [REDACTED]. Review of Resident #56's (MONTH) (YEAR) MAR indicated [REDACTED]. Tylenol 1000 mg which was ordered for moderate pain was not administered during the month of (MONTH) (YEAR). Further review of Resident #56's (MONTH) (YEAR) MAR indicated [REDACTED]. Review of Resident #56's (MONTH) (YEAR) MAR indicated [REDACTED]. The above information was conveyed during an interview with the Director of Nursing and Nursing Home Administrator on (MONTH) 30, (YEAR) at approximately 2:00 p.m. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(f) Clinical Records 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 facility policy review, it was determined that the facility failed to follow protocol for [MEDICAL CONDITION] for one of 18 residents reviewed. (Resident #60) Findings include: Review of facility policy Emergency Procedure - [MEDICAL CONDITION] Management, last revised (MONTH) 2011, revealed that staff are not to attempt to place objects in the resident's mouth during a [MEDICAL CONDITION]. Review of Resident #60's clinical record revealed the resident had a [DIAGNOSES REDACTED]. Review of Resident #60's progress notes revealed a nurse's note on (MONTH) 30, (YEAR) which stated that at 11:25 a.m. this nurse notified to 'come see' resident by staff. Resident observed sitting in w/c (wheelchair) in common area. Non responsive to verbal/touch stimuli. Breathing/snoring sounds. Activity aid stated that she observed resident 'slumped' and then her arms/legs began to jerk. Assisted by 3 staff members into bed. VS (vital signs) noted 159/68 (blood pressure - normal is 120/80) HR (heart rate) @ 67 with resp (respirations) at 22 (normal is 10-20.) O2 (oxygen) applied for comfort at 3 LPM (liters per minute.) .Teeth clamped/washcloth able to be placed between teeth. The facility's failure to follow their policy for [MEDICAL CONDITION] by placing a washcloth in Resident 60's mouth during a [MEDICAL CONDITION] activity was discussed with the Nursing Home Administrator and Director of Nursing on (MONTH) 30, (YEAR) at 12:26 p.m. 28 Pa Code

Based on clinical record review and staff interview, it was determined that the facility failed to ensure an environment free of accidents and adequate supervisor for two of 4 residents reviewed. (Resident #44 and Resident #50) Findings include: Observation of Resident #44 on (MONTH) 27, (YEAR) at 4:37 p.m. revealed the resident utilized a wheelchair for mobility. Review of Resident #44's progress notes revealed a nurse's note on (MONTH) 30, (YEAR) which stated Resident was being moved from room down west hallway to common area by (staff member) when her foot caught on the carpet propelling the resident forward out of chair onto left side. Further review of the nurse's note revealed Wheelchair pedals were not in place during transport of resident. Interview with the Director of Nursing on (MONTH) 30, (YEAR) at 12:39 p.m. confirmed that staff should have utilized wheelchair pedals while transporting Resident #44 in the wheelchair. Review of Resident #44's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated (MONTH) 21, (YEAR) revealed the resident required an extensive assist of two staff persons while toileting. Review of Resident #44's progress notes revealed a nurse's note dated (MONTH) 12, (YEAR) which stated that the resident was found on the floor in the bathroom. The resident was left in the bathroom unattended while staff went to retrieve the resident's pajamas. Interview with the Director of Nursing on (MONTH) 30, (YEAR) at 12:39 p.m. confirmed that Resident #44 should not have been left unattended in the bathroom. Review of Resident #50's clinical record revealed a Quarterly MDS (Minimum Data Set -a resident assessment) dated, (MONTH) 21, (YEAR) stated that the resident Brief Interview for Mental Status (BIMS), was a 2 out of 15 which indicated that cognition was severely impaired. Observation during the initial tour on (MONTH) 27, (YEAR) at approximately 2:16 p.m. in Resident #50's room revealed the resident's over the bed table was next to the bed. On top of the overbed table a tube of the corticosteroid ointment [MEDICATION NAME]/[MEDICATION NAME]/menthol/[MEDICATION NAME] topical ointment 16-ounce with the following instructions: - apply to nostrils at bed time, A second 16-ounce container with the label of petroleum jelly was also observed on top of the over the bed table. The facility failed to ensure that Resident #50 environment was free of accidents. 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(c) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of clinical records and staff interviews, it was determined that the facility failed to provide non-pharmacological interventions for as needed anti-anxiety medications for one of six residents reviewed (Resident #32) Findings include: Resident #32's clinical record revealed a [DIAGNOSES REDACTED]. Further review of Residents #32's clinical record revealed Medication Administration Record [REDACTED]. An interview was conducted with the Director of Nursing on (MONTH) 30, (YEAR) at 10:13 a.m. confirmed that no pharmacological interventions were not adminsitered for the anti-anxiety medication. 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(c) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to identify specific, individualized target behavior and side effects for residents receiving antidepressant medications and/or to monitor for symptoms of tardive dyskinesia (irreversible involuntary movements of the tongue, lips, face, trunk, and extremities) for residents receiving antipsychotic medications for seven of 16 residents reviewed. (Residents A8, D3, D8, D13, E3, F5 and F6). Findings include: Review of Resident A8's electronic record revealed that the resident was admitted to the facility on [DATE] with the a [DIAGNOSES REDACTED]. Review of the resident's current physician orders [REDACTED]. Interview with Employee E1, a licensed nurse on May 17, 2016 at approximately 12:00 p.m. revealed that the facility does not identify behaviors related mood to monitor for determining the benefit of continuation of the antidepressant or initiating gradual dose reduction. In addition, Employee E1 confirmed that side effects of antidepressants drugs were not specifically being identified and monitored. Review of Resident D3's clinical record revealed that the resident was readmitted to the facility on [DATE] and has the [DIAGNOSES REDACTED]. Review of Resident D3's May 2016 Medication Administration Record [REDACTED]. The medications were: [MEDICATION NAME] 120 milligrams (mg) daily, [MEDICATION NAME] 25 mg at bedtime and [MEDICATION NAME] XL 450 mg every day. Review of the resident's clinical record revealed no documented evidence in regard target behaviors being monitored for the usage of the antidepressants medications and no documentation of the monitoring of potential side effects of the antidepressant medications. Review of Resident D13's clinical record revealed that the resident was readmitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. Review of the resident's May 2016 Medication Administration Record [REDACTED]. Review of the resident's clinical record revealed no documented evidence in regard to the target behaviors being monitored for the usage of the antidepressant medication and no documentation of the monitoring of the potential side effects of the antidepressant medication. Review of Resident E3's clinical record revealed that the resident was admitted to the facility on [DATE] and had the [DIAGNOSES REDACTED]. Review of the Resident E3's May 2016 Medication Administration Record [REDACTED]. Review of the resident's clinical record revealed no documentation in regard to the target behaviors being monitored for the usage of the antidepressant medication and no documentation of the monitoring of the potential side effects of the antidepressant medication. Review of Resident F5's clinical record revealed that the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed no documentation in regard to the target behaviors being monitored for the usage of the antidepressant medication and no documentation of the monitoring of the potential side effects of the antidepressant medication. Review of Resident F6's clinical record revealed that the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed no documentation in regard to the target behaviors being monitored for the usage of the antidepressant medication and no documentation of the monitoring of the potential side effects of the antidepressant medication. Resident D8's [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of Resident D8's Behavior Monitoring Flow Records for February, March, April and May 2016, revealed that there were no specific target behaviors identified for the [DIAGNOSES REDACTED]. Interview with the Nursing Home Administrator and the Director of Nursing on May 13, 2016 at 10:30 a.m. confirmed that the facility did not routinely monitor the target behaviors and side effects of residents on antidepressants. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the concerns of a family member acting on a resident's behalf, was investigated for one of 16 residents reviewed (Resident CL3). Findings include: Review of Resident CL3's clinical record revealed an admitted [DATE] with a [DIAGNOSES REDACTED]. Interview with licensed nursing staff, Employee E2 on May 13, 2016 at 1:45 p.m. to discuss a grievance brought up by Resident CL3's family in regard to an incident that occurred on the evening shift of April 21, 2016 where Resident CL3's family member stated that the resident was left alone in the bathroom and did not have her oxygen on as ordered. The resident became short of breath. Licensed nursing staff, Employee E2 stated that she was aware of the grievance and did speak with a family member on April 22, 2016 when the family called her to discuss the complaint about the care that was given to her mother the evening before. Licensed nursing staff, Employee E2 stated that she listened to the complaint from Resident CL3's family member, but did not fully investigate what occurred the evening in question and was not fully sure what really occurred on April 21, 2016. Interview with the Nursing Home Administrator and the Director of Nursing on May 17, 2016 at 1:45 p.m. confirmed that the licensed nursing staff, Employee E2 was notified by the residents family member on April 22, 2016 of the care issue, and it was not investigated by the facility. 28 Pa Code 211.5(f) Clinical Records Previously cited: 3/23/2015 28 Pa Code 211.10(d) Resident Care Policies Previously cited: 03/23/2015, 11/02/2015 28 Pa Code 211.12(d)(1)(2)(5) Nursing Services Previously cited: 3/23/2015, 11/2/2015

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment was completed accurately to reflect the resident 's status for one of 16 residents reviewed (Resident F6). Findings include: Review of Resident F6's clinical record revealed an original admitted to the facility on [DATE] and readmitted to the facility from the hospital on November 25, 2015. Review of Resident F6's clinical record revealed that the resident had an admission MDS (Minimum Data Set-a periodic assessment of residents to determine the residents current physical and cognitive functioning) completed on December 1, 2015. Review of the MDS revealed that at Section E-titled Behavior E1100-Change in Behavior or Other Symptoms was documented as number 3 (N/A because no prior MDS assessment). Review of the resident's clinical record revealed that the resident did have a prior MDS completed to be able to compare if there was any behavior changes in the residents current health status. Also on this MDS, at Section K- titled Swallowing/Nutritional Status K0200 Height and Weight, the area for the documentation of the weight was - dashed. Interview with the Nursing Home Administrator on May 16, 2016 at 1:00 p.m. revealed that the change of behavior section was not completed correctly and the weight was not available because a weight was not obtained. 28 Pa Code 211.5(f) Clinical Records Previously cited: 03/23/2015, 11/02/2015 28 Pa Code 211.12(d)(1)(2)(5) Nursing Services Previously cited: 03/23/2015, 11/02/2015

Based on clinical record review and staff interview, it was determined that the facility failed to timely notify the hospice agency of a delay in the delivery of a pain medication for one of three resident reviewed, which resulted in actual harm to Resident B12. Findings include: Review of Resident B12 clinical record revealed that the resident was readmitted to the facility from the hospital on October 1, 2015 with the [DIAGNOSES REDACTED]. flow to meet the body's needs). Review of Resident B12 clinical record revealed that a hospice (a concept of care designed to provide comfort and support to patients and their families when a life-limiting illness no longer responds to cure-oriented treatments) order for consultation and treatment was obtained from the physician on October 5, 2015 and hospice services were initiated on October 6, 2015. Further review of the hospice clinical record notes revealed that the hospice admission nurse completed the initial evaluation at approximately 10:00 a.m. on October 6, 2015. Further review of the clinical record revealed that on October 6, 2015, the resident received [MEDICATION NAME] (medication used to treat many medical conditions, including: excessive mucus production and excessive production of saliva production) at 1:19 p.m. and again at 3:01 p.m. The resident was also noted to be very restless at 3:02 p.m. and [MEDICATION NAME] .25 milligram was given. Further review of the clinical record revealed that a phone call was placed to the hospice agency at 4:06 p.m. to report the change in condition and recommendations were made to help alleviate air hunger and restlessness with new medications. According to the clinical record the following order was approved by the physician and forwarded to the pharmacy on October 6, 2015 at 4:20 p.m., for the antianxiety medication [MEDICATION NAME] 2 milligrams/milliliters .5 milligrams by mouth every four hours for anxiety and restlessness and pain medication [MEDICATION NAME] liquid milligram/milliliters milligram every three hours for pain. Further review revealed that the physician was contacted again on October 6, 2015 at 5:04 p.m. and ordered [MEDICATION NAME] 5 milligram for pain and shortness of breath, every hour as needed until the [MEDICATION NAME] liquid arrived. Interview was conducted with the Director of Nursing on November 2, 2015 at approximately 11:00 a.m. which revealed that [MEDICATION NAME] liquid was only available through the pharmacy where the pain medication [MEDICATION NAME] was available through the emergency box. The pharmacy delivered medications at night and the [MEDICATION NAME] liquid arrived at 10:16 p.m. (a total of 6 hours after the initial order). Family interview conducted on November 3, 2015 at approximately 9:15 a.m. revealed that in the afternoon of October 6, 2015 approximately 3:00 p.m. Resident B12 began to sound like she was gurgling and became restless. It was further stated during interview that the facility contacted the physician and the orders were changed but the medication did not appear to be helping, her eyes were as big as saucers and she was gasping for air. Nursing staff was asked to address the resident condition and the resident's family was informed that the facility was waiting for this medication to arrive and it would alleviate the resident condition. During family interview it was stated that the medication did not come until around 10:00 p.m. She was suffering that whole time and they did not call hospice or the doctor for further instructions. Hospice was supposed to help her die comfortably, and she was not comfortable until the next day and then she passed. Further review of the clinical record revealed a nursing note dated October 6, 2015 at 11:09 p.m. from the licensed nursing staff which stated: Very restless and SOB (short of breath) most of the shift, did not eat dinner but fluids offered. [MEDICATION NAME] PRN (as needed) medications administered at 4:26 p.m., 5:25 p.m., 6:59 p.m., 8:00 p.m., and at 10:00 p.m. with little or no effect, family by the bedside all shift. A second interview with the Director of Nursing occurred on November 2, 2015 at approximately 2:30 p.m. that if the nurse felt the PRN (as needed) medications were ineffective that it would be expected that nursing would call the physician or hospice agency for further recommendations. An interview with the hospice agency Employee E3 occurred on November 2, 2015 at approximately 1:35 p.m. that revealed the hospice agency was only called at 4:06 p.m. on October 6, 2015 p.m. and no further calls were received. The hospice agency also stated that they can use local pharmacies to obtain medications if the facility is unable to obtain medications quickly. The facility failed to notify the hospice agency when Resident B12 experienced pain and discomfort, relating to the dying process, and they were unable to obtain prescribed medications from the pharmacy until 5 hours after the symptoms began which resulted in actual harm to Resident B12. 28 Pa Code: 211.12 (c)(d)(1)(3)(5) Nursing services Previously cited 3/23/2015 28 Pa 211.10(a) Resident care policies Previously cited 3/23/2015

Based on clinical record review and staff interviews, it was determined that the facility failed to assure that physician orders [REDACTED]. Findings include: Review of Resident C2 ' s February 2015 and March 2015 physician orders [REDACTED]. Further review of the orders revealed an order for [REDACTED]. Further review indicated a weight gain on February 17, 2015 to February 18, 2015 of three pounds. Additionally, from March 9, 2015 to March 10, 2015 there was a three pound weight gain. There was no evidence that the [MEDICAL CONDITION] clinic was notified of these weights. Interview with the nursing home administrator on March 23, 2015 at approximately 10:30 a.m. confirmed that the clinic was not notified. Review of Resident D8 ' s, January 5, 2015 physician's order [REDACTED]. Review of Resident D8's Medication Administration Record [REDACTED]. Further review of Resident D8's physician's orders [REDACTED]. During an interview on March 20, 2015 at 11:30 a.m., the Director of Nursing confirmed that there was no documentation to indicate that Resident D8 ' s [MEDICATION NAME]was administered at bedtime on January 5, 2015 and was uncertain what occurred on the listed days that the [MEDICATION NAME] (insulin) with breakfast was administered when it should not have been administered. Review of Resident J3's physician's orders [REDACTED]. Observation during medication pass of licensed nurse, Employee E 3 on March 19, 2015 at 10:50 a.m. revealed that the employee removed a patch from the resident's back dated March 18, 2015. The employee then applied a new [MEDICATION NAME] which was dated March 19, 2015. Interview immediately after the observation revealed that Resident J3 ' s patch dated March 18, 2015 should have been removed the night before. Review of Resident CL2's clinical record revealed that the resident was discharged from the facility on January 9, 2015. Review of fax communication to the physician dated January 7, 2015 revealed a request for an order for [REDACTED]. There was no actual order to discharge the resident out of the facility. 28 PA Code 211.5(f) Clinical records 28 PA Code 211.10(c) Resident care policies 28 PA Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and interview with staff, it was determined that the facility failed to maintain complete and accurate clinical records for two of 16 residents reviewed (Residents D8 and H9). Findings include: Review of Resident H9's physician's order dated September 22, 2014, directed staff to change the diet to no concentrated sweets (NCS) diet. Review of the nutrition assessment dated [DATE], and the nutrition quarterly review dated December 19, 2014, indicated that the diet was regular. Review of the physician's orders dated March 9, 2015, indicated that the diet was regular. A physician's order dated March 12, 2015, was obtained to change the diet to NCS. Interview with the Nursing Home Administrator on March 20, 2015, at 10:10 a.m. revealed that Resident H9 has been receiving a NCS diet since September 29, 2014, and that the diet had not been changed on the monthly physician's orders. Review of Resident D8's physician's order dated March 11, 2015 revealed [DIAGNOSES REDACTED].) Review of Resident D8's Medication Administration Record [REDACTED]. Review of Resident D8 ' s clinical record revealed that there was no physician's order available for the administered medication for the period January 9 to February 12, 2015. During an interview on March 20, 2015 at 11:30 a.m., the Director of Nursing indicated that licensed nurse; Employee E4 obtained a verbal order for the insulin injection but failed to document the verbal order. an order written [REDACTED]. The facility failed to ensure complete and accurate documentation. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of the Pennsylvania Code, Title 49, Professional and Vocational Standards, Chapter 21, State Board of Nursing, clinical record reviews, facility policies and procedures, observations and staff interviews, it was determined that the facility failed to meet the standards of quality nursing during the administration of medications ordered by the physician and in accordance with professional standards for one of three residents observed (Resident J3). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, Chapter 21, State Board of Nursing, dated April 6, 2013, in Subchapter B. Practical Nurses, Section 21.145(a)(b) Functions of a Licensed Practical Nurse (LPN), states that a LPN is prepared to function as a member of the health care team based on preparation, knowledge, experience in nursing and competency; administers medications and carries out therapeutic treatment orders for the individual. Review of Facility ' s policy for administration of eye drops dated October, 2007 revealed its policy is to administer ophthalmic solution into the eye in a safe and accurate manner. It revealed when two or more different eye solutions must be administered on the same medication pass, it is suggested that 5-10 minutes be allowed between administrations of the different medications or as indicated by the manufacturer. This will allow sufficient time for the medication to spread over the eye surface and be absorbed, therefore minimizing dilution or " washing out. " It reveals to wait 10 minutes between [MEDICATION NAME]/[MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]) and other eye solutions per manufacturer. Review of Resident J3's physician's orders [REDACTED]. from the eyelids), apply every morning to each eye for Blepharitis ( inflammation of the eyelids) . Observation of licensed nurse, Employee E3, during the medication pass on March 19, 2015 at 10:50 a.m., revealed that Employee E3 administered Refresh [MEDICATION NAME] one drop into both of the resident ' s eyes, after 2 minutes the employee administered [MEDICATION NAME] Marleate 0.25% one drop into both of the resident ' s eyes, waited one minute (less than 2 minutes) , after which Employee E3 cleaned both eyes of the resident ' s upper and lower eyelid areas with [MEDICATION NAME] lid scrub pad. During an interview on March 19, 2013 at 2:30 p.m., Employee E3 indicated that she usually waits 3-5 minutes between eye drop administration and always used the [MEDICATION NAME] lid scrub last. F281 CFR 483.20(k)(3)(i) Services Provided Meet Professional Standards. 28 Pa. Code: 211.10(a) Resident care policies. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on observations and staff interviews it was determined the facility failed to ensure that the ventilations ducts from two furnaces were maintained in a safe manner. Findings include: During the environmental tour on April 7, 2014 at 9:45 a.m. with Employees E1 and E3, it was observed that the ventilation ducts that ran from two natural gas furnaces and through the wall to the outside contained a hole approximately twelve inches in length by eight inches in height, with jagged rusted edges indicating corrosion. The hole allowed the escape of the exhaust fumes. The natural gas furnaces heated water for the skilled nursing units. The observation was confirmed by Employee E3 at the time of the finding. 28 PA Code 201.18(b)(1)(3)(e)(1) Management 28 PA Code: 207.2 (a) Administrator's responsibility

Based on review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to consistently provide restorative nursing services for ambulation for one of 16 residents reviewed (Resident G1). Findings include: Review of facility policy "Restorative Nursing" revised January 2009, revealed that the therapy department will establish an individualized program and goals for each resident on the restorative program. The individualized program ( listing goals and interventions) will be documented on the interdisciplinary care plan by restorative nurse or designee. Restorative care would continue while the resident continued to show progress towards goals. The goal of a maintenance program was to maintain residents at their present level of functioning. The nurse would complete monthly summaries on the flowsheets. Review of Resident G1's annual assessment dated [DATE], included [DIAGNOSES REDACTED]. Review of physical therapy documentation dated November 1, 2012 included a referral for restorative therapy and that Resident G1 was to ambulate with wheeled walker with assist of two persons for 100 feet twice. Review of care plan revealed Resident G1 had impaired physical mobility related to weakness and was to receive restorative ambulation at least five days weekly. Review of Resident G1's restorative nursing ambulation program flow sheet for November 2012 indicated resident ambulated 16 times, averaged 86.5 feet, and that restorative staff was unavailable 6 times and the resident refused twice. Review of the monthly restorative note dated November 26, 2012, indicated resident had recently started a restorative program and was to continue. Review of quarterly assessment dated [DATE], indicated that the resident ambulated only once or twice with one person assisting. Review of restorative flow sheet for December 2012 indicated resident ambulated eight times, averaged 58 feet, and restorative staff was unavailable nine times and the resident refused five times Review of the monthly summary restorative note dated December 28, 2012, indicated resident able to ambulate up to 75 feet; will continue as maintenance. Review of Resident G1's restorative flow sheet for January 2013 indicated resident ambulated seven times, averaged 35 feet, and restorative staff was unavailable six times and the resident refused 13 times. Review of nurse's note dated February 1, 2013, for restorative nursing stated "One month follow up since leg exercises and ambulation program change to maintenance. Continue current programs.". Review of restorative flow sheet for February 1 - 21, 2013, indicated that the resident walked four times and averaged five feet and refused six times. Interview with nursing Employee E4 on February 21, 2013, at 11:45 a.m. revealed that restorative is unavailable if staff is sick, light duty, or a second staff member is not available to assist. Interview with licensed nurse Employee E5, on February 22, at 10:15 a.m confirmed that Resident G1 is not ambulating as much and that the goals should have been reevaluated. There was no evidence that Resident G1 had been reassessed for factors involved in the lack of participation in the ambulation programs or that goals for the program had been reevaluated. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.10(c) Resident care policies Previously cited 3/20/12 28 Pa. Code: 211.12(d)(5) Nursing services Previously cited 3/20/12, 2/07/2011

Based on observations and staff interviews the facility failed to dispose of expired medications for one of two nursing units toured (first floor nursing unit). Findings included: Review of facility's policy titled medication storage, storage of medication dated September 2010 revealed that outdated medications are disposed of according to procedures for medical disposal. Observation on February 19, 2012 at 1:30 p.m. of the first floor medication room's refrigerator with licensed nursing Employee E3, revealed a box of Anucort HC (medication used to treat swollen veins and itch in the rectum) 25 milligrams rectal suppositories. The box contained 100 suppositories and they had expiration date of December 2011 on them. Licensed nursing Employee E3 at the time of observation confirmed that the medications had expired. Interview with the Director of Nursing in the morning on February 20, 2013 revealed that the expired medications should have been removed by the pharmacy department and were not, and that the nursing staff should have checked to ensure that there were no expired medications in the refrigerator. 28 Pa. Code 201.18 (b)(3)(e)(1) Management 28 Pa. Code 211.9 (j) Pharmacy services 28 Pa. Code 211.12 (d)(3) Nursing services Previously cited 3/20/12, 2/07/2011

Based on observations and staff interviews, it was determined that the facility failed to provide nursing care which promoted residents' dignity and respect for two of 45 residents on the first floor nursing unit (Resident E1 and D15). Findings include: Observation of the first floor nursing alcove, on March 14, 2012 at 4:25 p.m., revealed that upon the request of licensed nursing employee E3, staff had transported and grouped four residents together, Residents E2, E9, D15 and D17. Licensed nursing employee E3 was observed, on March 14, 2012 at 4:30 p.m., measuring Resident D15's sugar level in the blood, in the presence of Residents E2, E9 and D17. After obtaining the blood glucose results for Resident D15, staff were requested to remove Resident D15 from this alcove area. Observation, on March 14, 2012 at 4:45 p.m., revealed that staff had now transported Resident E1 to this nursing alcove. Licensed nursing employee E3 then both measured and verbally announced Resident E1's sugar level results, in the presence of Residents E2 and D17. Final observation, on March 14, 2012 at 4:50 p.m., of the first floor nursing alcove, revealed the presence of Residents E1, E2, D17, and the return of Resident D15 and D15's family member. Licensed nursing employee E3 was observed, on March 14, 2012 at 4:54 p.m., administering a subcutaneous injection to Resident E1's abdomen, in the presence of E2, D17, D15 and D15's family member. During an interview on March 14, 2012 at 4:35 p.m., licensed nursing employee E3, confirmed that sometimes those residents which require a blood glucose check are brought to the nursing alcove. Interview with Administrator and Director of Nursing, on March 20, 2012 at 12:45 p.m., confirmed that staff should not be checking blood glucose measurements or administering subcutaneous injections in an area that lacks visual privacy. 28 Pa. Code: 201.29(j) Resident rights 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 2/07/2011

Based on review of facility policy, clinical record review and interviews with staff, it was determined that the facility failed to follow physician orders [REDACTED]. Findings include: Review of the facility bowel protocol, revised January 2009, revealed that if the resident had not had a bowel movement for nine shifts then one ounce of Milk of Magnesia (a laxative) would be administered on the evening (3-11) shift. After 12 shifts with no bowel movement, a [MEDICATION NAME] suppository would be administered on the night shift (11-7) no earlier than 5:00 a.m. If the resident had not had a bowel movement by 2:00 p.m. the day shift (7-3) would administer a Fleets enema. After 15 shifts with no bowel movement, a full assessment would be done and the physician notified. Review of the Resident A12's care plan dated August 26, 2011 directed the staff to follow the bowel protocol and administer bowel medication as directed for this resident. Review of Resident A12 [DIAGNOSES REDACTED].The resident had experienced recent rectal bleeding and discomfort after a bowel movement as recorded in the nursing notes dated March 4, 2012. Physician orders [REDACTED]. Review of the residents bowel record for December 25, 2011 through December 31, 2011, a total of 17 shifts, revealed that the resident had no recorded bowel movement. On December 29, 2011, a total of 13 shifts, the resident was offered Milk of Magnesia laxative but refused. There was no further documentation relating to how the staff managed the refusal or further addressed bowel management or assessment. Review of Resident A12's bowel record for December 31, 2011 through January 6, 2012, a total of 17 shifts, revealed that the resident had no recorded bowel movement. On January 4, 2012 the resident received Milk of Magnesia, however this was given on shift 13 rather than shift 9, one full day later than directed in the bowel protocol. Review of the Resident A12's bowel record for January 23, 2012 through January 28, 2012, a total of 14 shifts, revealed that the resident had no recorded bowel movement and did not receive a laxative on shift 9 as outlined in the bowel protocol. Review of Resident A12's bowel record for February 6, 2012 through February 12, 2012, a total of 17 shifts, revealed that the resident had no recorded bowel movement. The resident did not receive a laxative until shift 16, ( five days) on February 11, 2012. The Director of Nursing confirmed, on March 19, 2012 at 10:00 a.m., that the bowel protocol for Resident A12 was not being followed as written. Review of Resident E13's quarterly assessment, dated December 28, 2011, revealed that resident was continent of bowel and physician progress notes [REDACTED]. Current physician orders [REDACTED]. Review of the bowel documentation for Resident E13's revealed that the resident had no recorded bowel movement from January 11, 2012 through January 15, 2012, a total of 11 shifts; from February 15, 2012 through February 18, 2012, a total of 11 shifts and March 9, 2012 through March 13, 2012, a total of 12 shifts. There was no documented evidence on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s constipation. Interview with Director of Nursing, on March 16, 2012 at 1:00 p.m., revealed that secondary to Resident E13's bowel records, for January 2012, February 2012 and March 2012, licensed staff would have been expected to administer something to resident to relieve constipation. The facility failed to follow their established bowel protocol and provide the specifically outlined interventions to assure comfort and avoid constipation and possible bowel complications for Residents A12 and E13. Review of Resident B8's physician's orders [REDACTED]. Review of Resident B8 ' s eye consult documentation revealed that the resident's last eye examination was completed on July 30, 2010. The consult indicated that the resident had a cataract in the left eye and also needed a revist 8 months from July 30, 2010. Review of facility's documentation during the onsite visit revealed that the resident had an eye appointment for March 30, 2011 but that the resident's husband cancelled the appointment. Interview on March 20, 2012 at 11:00 a.m. with licensed nursing employee E5 revealed that she could not explain why the appointment was not rescheduled after it was cancelled also that the resident should have had an annual eye examination but did not have an exam. Interview with the Director of Nursing, on March 20, 2012 at 12:00 p.m., confirmed that Resident B8 should have had an eye examination within the past year. 28 Pa. Code: 211.5(f) Clinical records Previously cited 2/07/2011 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services Previously cited 2/07/2011

Based on review of clinical record, review of facility documentation and staff interview, it was determined that the facility failed to provide adequate supervision and monitoring to ensure the safety of a resident with falls for one of 16 residents records reviewed. (Resident B13 ) Findings include: Review of Resident B13's physicians orders dated March 10, 2012 revealed a [DIAGNOSES REDACTED]. Red blood cells provide oxygen to body) and Re-Occurrent Falls. Resident B13's comprehensive assessment dated January 25, 2012 also revealed a [DIAGNOSES REDACTED]. The assessment revealed that Resident B13 had an impairment with temporal orientation ( an assessment where an individual reports accurate year, month and day), an impairment in his ability to register and recall new information, and also needed extensive assistance of one staff person for hygiene, transfer and ambulation. Review of the facility's fall risk evaluation dated January 19, 2012 revealed that Resident B13 was a high risk for falls. Review of the resident's care plan for falls dated May 10, 2011 included as part of it's interventions that staff were not to leave the resident unattended in the bathroom. Review of nursing notes dated January 30, 2012 at 9:00 a.m. revealed that the resident had fallen, was observed on the bathroom floor with a 3 centimeter laceration on the left thumb/finger area and the area was sutured by the physician with 12 sutures. physician's orders [REDACTED]. Review of the facility's investigation into the incident revealed that the resident was left in the bathroom alone by a staff member. The facility indicated in it's investigation of the incident that all staff were re-educated to never leave resident's who are considered to be at a high risk for falls, alone in the bathroom. Further review, of the nursing notes dated February 10, 2012 at 9:50 p.m. revealed that the resident had fallen in the bathroom again, sustained a 12 centimeter skin tear in his left hand and the skin tear was closed with 9 steristrips ( thin adhesive strips which can be used to close small wounds). Review of the facility's investigation into the incident revealed that the resident was left in the bathroom alone by Employee E4. Review of the facility's education record for staff who were educated to not leave residents alone in the bathroom revealed that Employee E4's name was not included. Interview with the Director of Nursing on March 20, 2012 at 11: 30 a.m. confirmed that the resident should not have been left alone in the bathroom and that Employee E4 was a temporary staff and had not been included in the list of staff that were previously educated in the prevention of falls of residents in the bathroom. The facility failed to follow it's care plan for Resident B13, failed to provide adequate monitoring and supervision for Resident B13 who was identified to be at risk for falls. 211.10(d) Resident care policies Previously cited 2/07/2011 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited deficiency 02/07/2011