Every finding on record at Langhorne Gardens Health & Rehabilitation Center

Based on clinical record review and staff interview, it was determined that the facility failed to complete a comprehensive assessment for one of 24 sampled residents. (Resident 2) Findings include: Clinical record review revealed that Resident 2 expired and was discharged from the facility on [DATE]. There was no Minimum Data Set (MDS) assessment completed to reflect the resident's discharge from the facility. In an interview on [DATE], at 9:57 a.m., the Administrator confirmed an MDS assessment had not been completed for Resident 2's discharge from the facility.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department and on one of two unit pantries. (Green wing) Findings include: Review of the policy entitled, Storage of Dry Food, last reviewed January 10, 2023, revealed that food was to be stored in a manner to avoid contamination and protect food quality. Review of the policy entitled, Storage of Refrigerated Foods, last reviewed January 10, 2023, revealed that refrigerated items were to be labeled and dated and bulk condiments were to be dated with date opened. Observations during the kitchen tour on November 27, 2023, beginning at 9:35 a.m., revealed the following: In dry storage, there were three large bins. One bin contained several packages of pasta, loose pasta that had spilled from a package, and multiple condiment packets. The second bin contained undated pasta packages and condiment packets. The third bin contained flour and the lid did not cover the length of the bin, which exposed the flour to the air. In the walk in cooler, there was an opened container of barbecue sauce that was not dated. In the trayline cooler, there were two pitchers of cranberry and orange juice that were not dated or labeled. There were two cups of poured prune juice that were not dated or labeled. In the freezer, there were two packages of spinach removed from the original packaging and not dated. In an interview on November 27, 2023, at 10:00 a.m., the Food Service Director confirmed the items should have been labeled and dated and were not. Observation of the Green wing unit pantry on November 29, 2023, at 11:10 a.m., revealed the inside of the microwave contained dried food debris and a black substance. Inside the refrigerator, there were multiple rust spots that were along the length of the back panel. The water drain line inside the refrigerator had a brown substance. In an interview on November 29, 2023, at 11:20 a.m., Licensed Practical Nurse (LPN) 1 confirmed the microwave and refrigerator were used for residents, CFR 483.60(i) Food Safety Requirement Previously cited 12/6/22 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(2.1) Management.

Based on clinical record review, observations, and staff interview, it was determined that the facility failed to provide interventions to prevent pressure ulcers for one of 29 sampled residents. (Resident 57) Findings include: Clinical record review revealed that Resident 57 had diagnoses that included aphasia, hemiplegia, and hemiparesis affecting the right dominant side following a cerebral infarction (difficulty communicating combined with muscle weakness and paralysis on the right side of the body after a stroke), dementia, unspecified,(a mild or mixed form of cognitive impairment), and diabetes mellitus (a disease that affects how the body uses blood sugar). Review of the Minimum Data Set assessment, dated November 6, 2023, revealed that Resident 57 had cognitive impairment, required extensive assistance from staff for bed mobility and dressing, and was at risk for developing pressure ulcers/injuries. On February 9, 2023, the physician ordered that Prevalon boots (a soft boot to elevate heels and reduce pressure) were to be placed on both feet while the resident was in bed for prevention of skin breakdown. Review of the care plan revealed that the resident was at risk for alteration in skin integrity due to right-sided weakness secondary to a stroke. There was an intervention for staff to elevate his heels and provide Prevalon boots when in bed . Observation on November 28, 2023, at 9:50 a.m., November 29, 2023, at 9:45 a.m. and 10:45 a.m., November 30, 2023, at 11:45 a.m. and at 1:35 p.m, revealed Resident 57 was in bed without Prevalon boots In an interview on November 30, 2023, at 12:25 p.m., the Director of Nursing confirmed that Resident 57 should have had the Prevalon boots applied to his feet while in bed. 28 Pa Code 211.12 (d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement safety interventions for one of five residents at risk for falls. (Resident 103) Findings include: Clinical record review revealed Resident 103 had diagnoses that included seizures, traumatic brain injury, and anxiety. The Minimum Data Set assessment dated [DATE], revealed Resident 103 required staff assistance for bed mobility and transfers. Review of the care plan identified that the resident was at risk for falls related to confusion. Review of progress notes dated September 30, 2023, revealed the resident was found on the floor after an attempt to stand and self transfer. The care plan was revised at that time and included an intervention for staff to place fall mats to both sides of the bed while the resident was in bed. Observations on November 29, 2023, at 11:16 a.m., and November 30, 2023, at 9:34 a.m. and 11:00 a.m., revealed Resident 103 was in bed and there was only one fall mat in place on one side of the bed. In an interview on November 30, 2023, at 11:52 a.m., the Director of Nursing confirmed Resident 103 should have had fall mats on both sides of the bed. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record review, and observation, it was determined that the facility failed to ensure that adequate catheter care was provided for one of three sampled residents with an indwelling urinary catheter. (Resident 78) Findings included: Review of the facility policy entitled, Indwelling Urinary Catheter Care Procedures, dated January 10, 2023, revealed that when a resident had a urinary catheter, an intervention was to prevent the urine in the tubing and drainage bag from flowing back into the bladder. Staff was to ensure that the urinary drainage bags be held or positioned lower than the bladder at all times, but not on the floor. Clinical record review revealed that Resident 78 was admitted to the facility on [DATE], with diagnoses that included stroke and urine retention. The Minimum Data Set assessment dated [DATE], indicated that the resident required extensive assistance from staff for activities of daily living and had an indwelling urinary catheter. The current care plan revealed that Resident 78 had an indwelling catheter and was at increased risk for infection. On November 28, 2023, from 1:47 p.m. to 2:10 p.m., Resident 78 was observed in bed with her catheter drainage bag hanging off the bed and directly touching the floor. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to prepare, store, and serve food under sanitary conditions in the kitchen. Findings include: Observations during the tour of the kitchen on December 4, 2022, at 9:44 a.m., revealed the following: an open, unsealed bag of thickener powder and a bag of granola with a use by date of August 4, 2022. The dispenser nozzle for the juice machine was directly on a box of cranberry juice and a wet substance had dripped onto three boxes of food items below the nozzle. During observation of the low temperature dish machine, a strip was utilized to test the sanitizer concentration following three dishwashing cycles. The sanitizer concentration was less than 50 parts per million (ppm) on each test. Observations during a subsequent tour of the kitchen on December 4, 2022, at 10:55 a.m., revealed the sanitizer concentration continued to be less than 50 ppm on repeat testing. There were various particles of debris and a white substance on the floor of the walk-in refrigerator. There was a frozen substance on the floor of the walk-in freezer. In an interview on December 5, 2022, at 1:01 p.m., the Director of Dietary Services confirmed that the dish machine did not dispense sanitizer or achieve the appropriate concentration of sanitizer solution during the observations on December 4, 2022. 28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to provide showers as scheduled/preferred to one of 22 sampled residents. (Resident 51) Findings include: Clinical record review revealed that Resident 51 had diagnoses that included muscle weakness. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident was totally dependent on staff for bathing. In an interview on December 5, 2022, at 11:55 a.m., Resident 51 stated that he preferred a shower and staff did not always offer to provide a shower per his schedule. Review of the bathing schedule revealed that Resident 51 was scheduled to receive a shower every Wednesday and Saturday during the evening shift. There was a lack of documentation to support that Resident 51 was offered a shower four of nine times in October 2022, and two of nine times in November 2022. In an interview on December 6, 2022, at 12:22 p.m., the Director of Nursing stated there was no evidence that the resident was bathed/showered in accordance with the schedule. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 22 sampled residents. (Resident 97) Findings include: Clinical record review revealed that Resident 97 had diagnoses that included diabetes mellitus. Review of the Minimum Data Set assessment dated [DATE], revealed that Resident 97 required extensive assistance from staff for activities of daily living. A physician's order dated June 23, 2022, directed staff to administer insulin lispro solution three units, three times daily for diabetes. Staff were to hold the medication if the resident's blood sugar was below 150 milligrams per deciliter (mg/dl). Review of the medication administration records for October, November, and December 2022, revealed that staff administered the insulin 79 of 121 times when the resident's blood sugar was less than 150 mg/dl. In an interview on December 6, 2022, at 10:29 a.m., the Director of Nursing confirmed that staff administered the insulin outside of the established parameters. CFR 483.25 Quality of care Previously cited 9/6/22 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, staff interview, and resident interview, it was determined that the facility failed to ensure that a physician ordered medication was obtained from the pharmacy for one of 22 sampled residents. (Resident 31) Findings include: Clinical record review revealed that Resident 31 had diagnoses that included diabetes. Review of the Minimum Data Set assessment dated [DATE], revealed the resident had no memory impairment and received insulin injections. On November 3, 2022, the physician ordered staff to administer Lantus insulin 50 units two times a day. The ongoing care plan revealed the resident was to be administered insulin as ordered by the physician to control unstable blood sugar related to diabetes. During an interview on December 4, 2022, at 12:55 p.m., the Resident stated the morning dose of insulin was not received and that doses were missed in the past. Review of medication administration records revealed the resident did not receive the Lantus insulin on November 19, 2022, at 9:00 a.m., and 5:00 p.m., and December 4, 2022, at 9:00 a.m. During an interview on December 4, 2022, at 1:05 p.m., LPN 1 stated the insulin was ordered from the pharmacy but was not delivered in time for that morning's dose. Review of nursing documentation for the dates of the missed insulin doses revealed that the medication had not been delivered from the pharmacy. CFR 483.45 Pharmacy Services Previously cited 1/12/22 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and resident interview, it was determined that the facility failed to ensure that a physician's order was implemented for one of five sampled residents. (Resident 5) Findings include: Clinical record review revealed that Resident 5 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse's notes revealed that the resident had a surgical wound on her left knee. On July 16, 2022, the physician ordered for staff to apply daily treatments to Resident 5's left knee. In an interview, on September 6, 2022, at 1:15 p.m. Resident 5 stated that staff do not always complete her wound treatment daily. Review of Resident 5's August 2022, Treatment Administration Record, revealed a lack of documentation that the treatment to her left knee had been completed on August 23, 28, 30, and 31, 2022. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide nail care to maintain good foot health for one of five sampled residents. (Resident 5) Findings include: Clinical record review revealed that Resident 5 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], indicated that the resident had no cognitive impairments, required extensive staff assistance for care, and was totally dependent on staff for bathing. On July 5, 2022, the physician ordered for a podiatry consult as needed. In an interview on September 6, 2022, at 1:20 p.m. Resident 5 stated that she needed to see a podiatrist and had not seen one since admission to the facility. Observation on September 6, 2022, at 1:50 p.m. with LPN 1, revealed that the resident's toenails were long and in need of nail care. During an interview on September 6, 2022, the Administrator reported that Resident 5 had not been seen by a podiatrist since admission to the facility. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide care and treatment in accordance with physician's orders and professional standards of practice, resulting in actual harm for one of five sampled residents receiving anticoagulant (blood-thinning) medication. (Resident 1) This deficiency is cited as past noncompliance. Findings include: Review of the facility policy entitled, Anticoagulation Policy, dated May 27, 2021, revealed that the purpose was to ensure that anticoagulant therapy was safely administered and monitored. In the event there was a change in medication dosage, all dosage changes were to be made on the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility policy entitled, Physician/Provider Orders, dated December 14, 2021, revealed that a physician's order shall be recorded exactly as the physician dictates it directly on a telephone order form or directly into the electronic health record. The order must then be transcribed to all appropriate areas (i.e eMAR, etc.) Clinical record review revealed that Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], indicated that the resident was alert and oriented, was able to eat with supervision after set-up, and received an anticoagulant (blood thinning) medication. The resident had a physician's order dated January 15, 2022, to increase the anticoagulant medication [MEDICATION(S)] ([MEDICATION(S)]) from five milligrams (mg) to six mg by mouth at bedtime related to presence of prosthetic heart valve. At that time the physician ordered a prothrombin time test with international normalized ratio (PT/INR) to determine if blood was clotting normally. (When elevated, the test indicates that blood is taking longer to clot and the risk of bleeding is increased.) A laboratory (lab) report from blood drawn on January 17, 2022, indicated that the resident had a PT greater than 100 seconds (normal range 9.6 to 12.2) and an INR that was greater than 10.00 (normal therapeutic range 3.50 to 4.50 for a person receiving anticoagulant medication with an artificial heart valve). The physician ordered that the resident's anticoagulant medication be held January 17, 2022, through January 22, 2022, and that a repeat PT/INR test be done on January 18, 2022. Nursing documentation noted that the lab was unable to draw a blood sample for the test on January 18, 2022 and the resident refused a test on January 19, 2022. A PT/INR drawn on January 21, 2022, (after the resident's anticoagulation medication had been withheld four days) indicated that the PT was 26.0 (high) and the INR was 2.64 (within therapeutic range). On that date, January 21, 2022, the nurse noted the PT/INR results and documented that the resident's [MEDICATION(S)] was to be restarted at a decreased dose of three mg. There was no evidence that a physician's order for [MEDICATION(S)] three mg was entered and the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . It was noted that the resident refused a PT/INR test that was ordered for January 24, 2022. A pharmacist's consultation report dated January 31, 2022, noted that a PT/INR test was ordered for January 24, 2022, and was not documented in the record. It was recommended that the test be completed with results communicated to the physician. The pharmacist noted that the rationale was due to the resident receiving [MEDICATION(S)] which had a warning describing potential for major, sometimes fatal bleeding and to avoid consequences, individuals should be constantly and continually assessed both clinically and through appropriate INR monitoring. A physician's progress note dated February 2, 2022, stated, mechanical aortic valve: will order stat INR. INR therapeutic (2.5-3.5), continue [MEDICATION(S)], monitor. There was no evidence that a physician's order was recorded or that an INR test was completed as the result of or following the physician's visit on February 2, 2022. A nurse's note dated February 15, 2022, reflected that Resident 1 experienced a change in condition and noted that the resident was staring and not verbally responsive or able to follow commands. The physician ordered the resident to be transferred to the hospital for evaluation and treatment. Review of hospital documentation dated February 15, 2022, indicated that a CT scan (type of x-ray that provides highly detailed images) of the head resulted in findings of subarachnoid hemorrhage with midline shift of the brain and acute right-sided subdural hematoma (bleeding of the brain). Blood drawn on February 15, 2022, at 10:24 p.m. revealed the resident's PT was greater than 250.0 seconds with INR of 21.5. On February 16, 2022, the hospital trauma surgeon noted that the resident became unresponsive at the nursing facility at approximately 8:00 p.m. on February 15, 2022, that there was no evidence of head trauma on examination, and that it appeared to be traumatic intracerebral hemorrhage. The physician noted that it would most likely require operative decompression (after reversal and correction of INR) which was declined by the family, who requested comfort measures only. In an interview on February 22, 2022, at 10:30 a.m., the Director of Nursing confirmed that Resident 1 received the wrong (greater) dose of [MEDICATION(S)] (six mg) January 22, 2022, through February 14, 2022, and that no PT/INR had been completed January 21, 2022, through February 15, 2022, when she was transferred and admitted to the hospital after becoming unresponsive. Due to the facility's failure to ensure that Resident 1 received care consistent with professional standards in accordance with physician's orders and recommendations and failure to adequately and continually assess the use of an anticoagulant, the resident suffered actual harm. Information submitted by the facility to the Department included the following corrective actions in response to the harm of Resident 1. The facility's investigation and implementation of the corrective measures began on February 16, 2022. A. The responsible party was notified on February 15, 2022, at 9:15 p.m. B. The resident's physician was notified on February 16, 2022, at 9:15 p.m. C. Upon review of the resident's clinical record on February 16, 2022, the Director or Nursing identified the medication error and missed laboratory test order. D. On February 16, 2022, an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held to formulate an action plan. Attendance included the Medical Director, Administrator, Director of Nursing, facility department heads, and additional staff. E. On February 16, 2022, an audit was completed by the Director of Nursing to ensure that all residents receiving [MEDICATION(S)] had proper laboratory test monitoring and that all tests were scheduled as ordered. All [MEDICATION(S)] orders were reviewed and checked for accuracy. F. On February 16, 2022, the Director of Nursing completed a medication regimen review for all residents to ensure proper reconciliation. G. Upon discovery of the medication error on February 16, 2022, immediate education regarding transcribing and reconciling medications, anticoagulation medication policy, and 24 hour chart checks was given to the Registered Nurse who failed to transcribe the change in [MEDICATION(S)] order. The subject nurse was also disciplined. H. On February 16, 2022, education was started and completed for all licensed nursing staff regarding facility anticoagulation medication policy, transcribing and reconciling new medication orders, and completing 24 hour chart checks. I. On February 16, 2022, a conference call was held with the Medical Director and the physician who failed to enter the order for a laboratory test to provide education regarding writing and endorsing physician's orders. J. On February 17, 2022, additional regular audits were implemented five times per week and had been completed on February 17, 18, and 21, 2022, at the time of the survey. Audits were to monitor and maintain ongoing [MEDICATION(S)] logs (which include dosage and laboratory value information) and accuracy and reconciliation of physicians' orders and progress notes. Audits of 24 hour chart checks were implemented for five residents weekly and had been completed February 17, 18, and 21, 2022, at the time of the survey. Audits will continue as described for a period of three months; at which time it will be reviewed by the QAPI committee. K. Upon hire, all licensed nursing staff are to receive education regarding the facility's anticoagulation medication policy and transcribing and reconciling physicians' orders. L. During the onsite survey conducted February 22, 2022, additional clinical records were reviewed and it was determined that residents receiving anticoagulant medication therapy were provided care in accordance with accurate physicians' orders and adequate monitoring. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review and staff interview, it was determined that the facility failed to accurately assess residents' weights to ensure that residents maintained acceptable parameters of nutritional status for four of eight sampled residents who were at nutritional risk. (Residents 1, 17, 42, 96) Findings include: Review of the facility policy entitled 'Weights Policy, last reviewed June 1, 2021, revealed that weights were to be obtained routinely in order to monitor the parameters of nutrition over time. Nursing was responsible for the determination of each individual's weight. The procedure for re-weights was for residents who weighed less then 100 pounds, all weight changes showing a gain or a loss of five pounds or more from the previous weight required a re-weight within 24 hours. For residents who weighed more then 100 pounds, all weight changes showing a gain or loss of three pounds or more from the previous weight required a re-weight within 24 hours. Clinical record review revealed that Resident 1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had cognitive impairments, and required set up help with eating. Review of the current care plan revealed that Resident 1 was at an increased risk for poor nutrition status due to dementia with an intervention to monitor her weight per protocol. Review of the weights revealed that on November 4, 2021, the resident weighed 141 pounds. On December 7, 2021, the resident weighed 132.6 pounds which was a 5.96% loss and a difference of 8.4 pounds. On December 8, 2021, the dietician noted the weight loss and recommended for staff to obtain a re-weight to validate the significant weight loss of 8.4 pounds. There was no documented evidence that the staff had obtained the re-weight as per the facility protocol and as per the dietician's recommendation. Clinical record review revealed that Resident 17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE], indicated that the resident had memory impairment, required extensive assistance with most activities of daily living, required set-up help for eating and had a weight loss. Review of the care plan identified the resident was at nutritional risk due to a history of weight loss and dysphagia. There was an intervention to monitor the resident's weight. Review of the weights revealed that on December 28, 2021, the resident's weight was 103.8 pounds. On January 5, 2022, the resident's weight was 97.2 which was a total loss of 6.6 pounds. On January 6, 2022, a dietician noted the weight loss and recommended for staff to obtain a re-weight to validate the significant weight loss of 6.6 pounds since December 28, 2021. There was no documented evidence that the staff had obtained the re-weight as per the facility protocol and as per the dietician's recommendation. Clinical record review revealed that Resident 42 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE], revealed the resident required supervision with eating. Review of the current care plan revealed that Resident 42 had an increased nutrition risk due to dementia with an intervention to monitor his weight per protocol. Review of the weights revealed that on July 14, 2021, Resident 42 weighed 236 pounds, and on August 11, 2021, he weighed 230 pounds, a difference of 6 pounds. On November 9, 2021, he weighed 230.8 pounds, and on November 12, 2021, he weighed 221.6 pounds, a difference of 9.2 pounds. There was no documented evidence that the staff had obtained the re-weight as per the facility protocol. Clinical record review revealed that Resident 96 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment December 14, 2021, revealed the resident required supervision with eating. Review of current current care plan revealed that Resident 96 had an increased nutrition risk due to food seeking behaviors and anxiety with an intervention to monitor her weight per protocol. Review of the weights revealed that on April 9, 2021, the resident weighed 365 pounds, and on May 11, 2021, 354.3 pounds, a difference of 10.7 pounds. On July 19, 2021 the resident weighed 354.6 pounds, and on August 26, 2021 she weighed 378.2 pounds, a difference of 23.6 pounds. On September 1, 2021, the dietician noted the weight gain and recommended for staff to obtain a re-weight to validate the significant weight gain of 23.6 pounds. On September 14, 2021 she weighed 290 pounds, a difference of 88.2 pounds from her previous weight of 378.2 pounds on August 26, 2021. On September 15, 2021, the dietician noted the weight loss and recommended for staff to obtain a re-weight to validate the significant weight loss of 88.2 pounds. On October 5, 2021 she weighed 318.2 pounds, a difference of 28.2 pounds from her previous weight of 290 pounds on September 14, 2021. On October 7, 2021, the dietician noted the weight gain and recommended for staff to obtain a re-weight to validate the significant weight gain of 28.2 pounds. On October 26, 2021 she weighed 307.6 pounds, a difference of 10.6 pounds from her previous weight of 318.2 on October 5, 2021. On November 9, 2021 she weighed 307 pounds, and on December 7, 2021 she weighed 314.6 pounds, a difference of 7.6 lbs pounds. There was no documented evidence that the staff had obtained the re-weight as per the facility protocol and as per the dietician's recommendation. In an interview on January 11, 2022, at 10:30 a.m., the Director of Nursing stated that the facility failed to obtain and document re-weights as per the facility protocol for the four aforementioned residents. 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(a) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that a call bell was accessible for three of 26 sampled residents. (Resident 70, 89, 93) Findings include: Clinical record review revealed that Resident 70 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated November 3, 2021, revealed that the resident was able to communicate needs to staff and required extensive assistance from staff for mobility and activities of daily living such as toilet use, grooming, and hygiene. On January 10, 2022, at 12:30 p.m., the resident was observed sitting in bed with her lunch tray in front of her on an over bed table. The call bell was located on the floor out of reach. The resident stated she needed help with her fork and knife. I asked if she knew where her call bell was and she stated she did not know. Clinical record review revealed that Resident 89 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated December 6, 2021, revealed that the resident was able to communicate needs to staff and required extensive assistance from staff for mobility and activities of daily living such as toilet use, grooming, and hygiene. On January 9, at 11:11 a.m., and January 10, 2022, at 12:50 p.m., the resident was observed laying in bed watching television. The call bell was located on the floor out of reach during both observations. The resident stated she did not where her call bell was. Clinical record review revealed that Resident 93 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated December 11, 2021, revealed that the resident was able to communicate needs to staff and required extensive assistance from staff for mobility and activities of daily living such as toilet use, grooming, and hygiene. On January 9, 2022, at 10:50 a.m., and January 10, 2022, at 12:40 p.m., the resident was observed laying in bed. The call bell was located on the floor out of reach during both observations. The resident stated she did not where her call bell was. In an interview on January 10, 2022, at 2:00 p.m., the Director of Nursing stated that the aforementioned residents were able to use their call bell. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, facility incident report review, observation and staff interview, it was determined that the facility failed to ensure that safety interventions were in place for one of ten sampled residents identified at risk for falls. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included dementia, history of falling, [CONDITION(S)] ([CONDITION(S)]), and [CONDITION(S)]. Review of the current care plan revealed that the resident was at risk to fall related to a history of falls, dementia, and gait/balance problems. On December 8, 2021, Resident 1 fell out of bed. Review of the facility's incident report dated December 8, 2021, revealed that staff was to place bilateral fall mats when the resident was in bed as an intervention to prevent future falls. On January 9, 2022, from 10:38 a.m. through 1:35 p.m., and January 10, 2022, from 9:50 a.m. through 11:52 a.m., Resident 1 was observed in her bed without bilateral fall mats. In an interview on January 11, 2022, at 10:15 a.m., the Director of Nursing confimed that Resident 1 was to have bilateral fall mats in her room. CFR 483.25(d) Accidents Previously cited 1/13/21 28 Pa. Code 211.12(d)(5) Nursing services.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to maintain accurate reconciliation records for controlled substances on one of four medication carts. (Green Nursing Unit, medication cart one) Findings include: Review of the facility policy entitled, Inventory Control of Controlled Substances, last reviewed June 1, 2021, revealed that the incoming and outgoing nurses were to count all Schedule II controlled substances and other medications with the risk of abuse or diversion at the change of each shift and document the results on a Controlled Substance Count Verification/Shift Count Sheet. The nurses were to perform the shift to shift counts of the accountable medications and were to reconcile the total number of controlled medications on hand, add newly received medications, and remove medications that were completed or discontinued from the inventory. The last person whose name appeared on the sheet was responsible for the cart. This shift to shift count was to be completed at the same time by both nurses. Following shift to shift count, both nurses were to sign the medication cart shift change record. Any discrepancies of the controlled substances were to be immediately reported to their supervisor. Observation of one of four medication carts on the Green Nursing Unit, medication cart 1 on January 10 at 11:45 a.m., revealed that the controlled substance log the facility used entitled, Narcotic and Hypnotic Inventory Sheet, had missing signatures from licensed staff between first shift January 4, 2022 through first shift January 10, 2022. The following times were: January 4-oncoming 11:00 p.m., January 5- outgoing 7:00 a.m., January 6-oncoming 7:00 a.m., January 6- outgoing 3:00 p.m., January 8-oncoming 11:00 p.m., January 9- outgoing 7:00 a.m., January 9-oncoming 3:00 p.m., January 9-outgoing 11:00 p.m. On January 10, licensed staff from the oncoming 7:00 a.m. shift had signed the outgoing 3:00 p.m., column prior to shift change and before the incoming 3:00 p.m. nurse counted the controlled substances. In an interview on January 11, 2022 at 11:00 a.m., the Director of Nursing stated that the signatures were not there at the aforementioned times as per facility policy. In addition, the Director of Nursing stated that the January 10, 2022 signature should not have been signed by the nursing staff prior to the end of the shift. CFR 483.45 Pharmacy Services Previously cited 1/13/21 28 Pa. Code 211.9 (i) Pharmacy Services 28 Pa Code 211.2 (d) (1) (5) Nursing Services

Based on resident interviews and a review of the resident council minutes, it was determined that the facility failed to ensure that a grievance was resolved in a timely manner for eleven of twelve alert and oriented sampled residents. (Residents 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12) Findings include: Review of the resident council minutes for September 2021, revealed that the residents stated that fresh water was not provided. Individual interviews between 10:15 a.m., and 1:30 p.m., on November 22, 2021, with Residents 1, 2, 3, 4, 5, 6 8, 9, 10, 11, 12, revealed they must either ring the call bell for fresh water or ambulate to the nurse's station and request fresh water because fresh water was not provided on a regular basis. 28 Pa. Code 201.29(j) Resident rights.

Based on resident interviews, observation and staff interview, it was determined that the facility failed to ensure that the residents were served lunch at an acceptable temperature on one of two nursing units and for ten of twelve alert and oriented residents. (Green Wing nursing unit, Residents 1, 2, 3, 4, 5, 8, 9, 10, 11, 12) Findings include: Resident interviews between 10:15 a.m., and 1:30 p.m., on November 22, 2021, with Residents 1, 2, 3, 4, 5, 8, 9, 10, 11, 12, revealed that lunch was often served cold, and that food was not always palatable. Observation of lunch served on the West Hall nursing unit on November 22, 2021, revealed the following: The food cart left the kitchen at 12:10 p.m., and arrived on the nursing unit at 12:12 pm., the last tray was served from the cart at 12:35 p.m. The temperatures of the food and beverages were as follow: Pork chop - 100 degrees Fahrenheit Mashed potatoes - 120 degrees Fahrenheit Vegetables - 100 degrees Fahrenheit Beef gravy -100 degrees Fahrenheit Coffee - 125 degrees Fahrenheit The hot items were cool to taste. In an interview on November 22, 2021, at 12:35 p.m., the Food Service Supervisor stated that the expectation was food at point of service was to be 135 degrees Fahrenheit. 28 Pa. Code 201.29(j) Resident rights.

Based on clinical record review and interview, it was determined that the facility failed to provide behavioral health services in a timely manner to one of three sampled residents. (Resident R1) Findings include: Clinical record review revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], indicated that the resident was alert and oriented, exhibited mood indicators of feeling down, [CONDITION(S)], and little interest and pleasure in doing activities. The assessment also indicated that the resident was administered anti-psychotic and anti-anxiety medications daily. Review of nursing documentation dated July 28, 2021, revealed that the resident was continuously screaming into the hallway and was verbally abusive toward staff. Review of a social services note dated July 29, 2021, revealed that the resident stated the following mood symptoms occurred daily: little interest, feeling down, trouble sleeping, trouble concentrating and moving slowly. The note further indicated that a referral was made for psychiatric services. On August 11, 2021, a nurse documented that the resident was continuously screaming for help and that she was sad and teary lately. On August 15, 2021, a nurse documented that the resident was continuously screaming and calling out and stated that she is scared at times and seems confused. On August 19, 2021, social services again noted that a psychiatric consult was placed. On August 20, 2021, a nurse documented that the resident was crying and stating that she wants to go home. On August 23, 2021, a nurse practioner noted that the resident was anxious and tearful. On August 27, 2021, a nurse documented that the resident was very tearful and yelling into the hall. On September 8, 2021, at 11:00 a.m., the resident was observed laying in bed. At this time, the resident stated that she has been very teary and does not understand why she is always calling out. There was no documented evidence that the resident had been seen by a psychiatrist since she was admitted to the facility. In an interview on September 8, 2021, the Director of Nursing stated that the psychiatric consult had not been completed as ordered by the physician in a timely manner. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observation during the tour of the kitchen on January 10, 2021, and staff interview, it was determined that the facility failed to store food under safe and sanitary conditions. Findings include: Review of the facility policy entitled, Storage of Refrigerated Foods, dated April 1, 2020, revealed that refrigerated items must have a label showing the name of the food and the date it should be consumed or discarded. If a food has not been used by a specific date, it was to be discarded. Cooked poultry pieces in broth or gravy were to be refrigerated for a maximum of two days. Observation during the initial tour of the kitchen on January 10, 2021, at 10:00 a.m., revealed that in the reach-in holding refrigerator there were three five-pound containers of cottage cheese with expiration dates of December 19, 2020, December 20, 2020, and January 1, 2021. There was one five pound container of sour cream with the expiration date of January 5, 2021. The facility cook (C1) confirmed that the items should have been discarded and proceeded to do so. In the walk-in refrigerator, there was a partial tray of prepared chicken pieces labeled and dated January 5, 2021. During an interview, C1 confirmed that the chicken should have been discarded. In the same refrigerator, five trays of plated pieces of cake were stored uncovered, with no label or date. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.6(c) Dietary services.