Every finding on record at Lebanon Valley Brethren Home

Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to ensure pain management was consistent with professional standards and failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one of 16 sampled residents. (Resident 18) Findings include: Clinical record review revealed that Resident 18 had diagnoses that included dementia, anxiety, and diabetes. There were physician's orders dated July 14, 2022, for staff to administer the narcotic pain medication, oxycodone, every four hours as needed for very severe pain, rating nine to 10 only. Review of Resident 18's care plan revealed the resident had chronic pain with interventions for staff to evaluate if interventions were effective, notify the physician if interventions were unsuccessful, and offer non-pharmacological interventions. In an interview on January 10, 2024, at 9:30 a.m., Resident 18 stated she was in pain. Review of the Medication Administration Records for December 2023, and January 2024, revealed that the resident received the as needed narcotic (oxycodone) on December 9 and 29, 2023, and January 6 and 10, 2024 for a pain rating less than the ordered nine to 10 parameter. The Resident received the as needed narcotic twice on December 29, 2023, and on January 2 and 6, 2024, without documented evidence that non-pharmacological interventions were attempted prior to administration. In addition, on December 9 and 29, 2023, and January 6 and 10, 2024, staff documented that the medication was ineffective or unknown. There was no documented evidence that the physician was notified. During an interview on January 11, 2024, at 12:58 p.m., the Director of Nursing confirmed that the oxycodone was given outside parameters and that there was a lack of documentation to support that non-pharmacological interventions for pain had been provided prior to the administration of as needed pain medication or that the physician was notified of the unsuccessful interventions. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, review of incident reports, and staff interview, it was determined that the facility failed to provide adequate supervision for a resident who exhibited behaviors and failed to ensure that an assessed safety intervention was in place in order to prevent falls for one of eight sampled residents who were at risk for falls. (Resident 120) Findings include: Clinical record review revealed that Resident 120 was admitted to the facility on [DATE], with diagnoses that included dementia with behavioral disturbance, [CONDITION(S)], [CONDITION(S)], restlessness, and agitation. Review of the current care plan identified the resident was at risk for falls due to dementia and poor safety awareness. There was an intervention since admission for staff to ensure that the resident had a chair and bed silent mobility detector (device to alert staff of unassisted transfers and ambulation) in place at all times. Review of the fall risk evaluation from admission revealed that the resident had a history of falling, had a weak gait (was weak when walking) and that he overestimated or forgot the limits of his own ability to ambulate safely which placed him at a high risk for falling. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment, had delusions, exhibited both verbal and physical behaviors over the last four to six days and that the behaviors interfered with the resident's care. In addition, the assessment indicated that the resident required supervision for transfers and walking, was not steady when he was walking, required assistance with toileting and had a history of falls. Review of nursing documentation revealed that on March 3, 2022, the resident exhibited aggression towards staff. On March 5, 2022, at 1:30 p.m., the resident was found on the floor near his bed. On March 6, 2022, at 2:34 a.m., the resident was noted as restless and was hollering out. On March 11, 2022, the resident was refusing his medications and was resistive to care. On March 13, 2022, at 10:05 a.m., the resident was noted as wandering on the unit and was agitated. On March 15, 2022, at 3:24 a.m., the resident was noted as restless and wandering on the unit. The resident was getting up and down in his chair and was unable to sit for very long. On the same day at 5:13 a.m., he was again noted with increased behaviors and was extremely restless. Again on the same day at 1:41 p.m., the resident was noted as refusing his medications. Review of an incident report dated March 15, 2022, at 7:40 p.m., revealed that the resident was found on the floor in his room with his head beside the dresser. The resident had taken himself to the bathroom and when walking back from the bathroom he fell and struck his head on the dresser drawer when he fell . It was noted that the chair alarm pad was in place but that it was not connected to the alarm box and therefore, the alarm did not sound to alert staff of the unassisted transfer out of the chair. Review of a witness statement revealed that before the fall, a staff member had assisted him to his chair after he had been wandering in the hallway. The statement indicated that the staff member forgot to plug the alarm from the bed to his chair and had left the room. Subsequently, the resident transferred himself out of the chair, walked to the bathroom, and fell on the way back from the bathroom. The facility failed to provide adequate supervision to a resident who had exhibited restless and wandering behaviors and failed to ensure that the assessed safety intervention (silent mobility chair alarm) had been in place at the time of the fall. In an interview on March 24, 2022, at 9:34 a.m., the Administrator stated that the assessed safety intervention had not been in place properly in order to activate the alarm at the time of the fall. 28 Pa. Code 211.12(d)(1)(5) Nursing services. .

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure that the attending physician was notified of a need for an alteration in treatment for one of four sampled residents. (Resident CL1) Findings include: Review of the facility policy entitled Notification of Changes, dated July 2020, revealed that staff were responsible to notify the physician timely of a significant change in treatment related to the health or safety of the resident. Clinical record review revealed that Resident CL1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On May 20, 2021, a physician ordered for staff to administer a medication Vitamin D-3 (supplement) sublingually in the evening every other day. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing notes revealed on May 20, 2021, a nurse documented that the Vitamin D-3 was not administered because the medication was not on hand. On May 24, 2021, a nurse documented that the Vitamin D-3 was not available and was not administered and that the pharmacy had been notified. On May 30, 2021, a nurse noted that again the Vitamin D-3 was not administered because it was not on hand. There was no documented evidence that the physican had been notified that the Vitamin D-3 was not being administered on the aformentioned three evenings. In an interview on June 21, 2021, at 1:05 p.m., the Administrator stated that the medication Vitamin D-3 in the sublingual format had not been made available until June 1, 2021. The Administrator further stated that there was no documented evidence that the physician had been notified of the medication not being administered. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, policy review and staff interview, it was determined that the facility failed to properly store food to prevent potential foodborne illness in three of seven kitchen areas. ([NAME], [NAME] Haven, and [NAME] Haven Greenhouses) Findings include: Review of the facility policy entitled, Food and Supply Storage dated [DATE], revealed that all food, non food items, and supplies used in food preparation were to be stored in a manner to prevent contamination and to maintain the safety of the food. Foods past the use by, sell-by, or enjoy by date should be discarded. Observation of the [NAME] Greenhouse dry storage area and refrigerator on [DATE], at 10:15 a.m., revealed three apples and one lemon with a discard date of [DATE]. There was one orange and American and Swiss cheese with a discard date of [DATE]. There was a can of apple crisp with a good through date of [DATE], and braised beef, marinara sauce, red cabbage, banana pudding and ham with a discard date of [DATE]. There was venison sweet bologna with no identied name, opened or discard date. The refrigerator was observed to have a dried sticky substance throughout the shelving. Under the kitchen sink there was a brown coffee substance and the bottom shelving was observed to be lifting from the base of the cabinet. Observation of the [NAME] Haven Greenhouse dry storage area and refrigerator on [DATE], at 10:45 a.m. revealed opened blueberry muffin mix, honey style muffin mix, mozzarella cheese, cheddar cheese, and turkey with no identified discard date. There was romaine lettuce with a discard date of [DATE], one cucumber with a discard date of [DATE], American cheese with a discard date of [DATE], three tomatoes with a discard date of [DATE], cheddar cheese with a discard date of [DATE], ham with a discard date of [DATE], and one orange and pear with an opened date of [DATE], with no identified discard date. The refrigerator was observed to have a dried sticky substance throughout the shelving. Observation of the [NAME] Haven Greenhouse dry storage area and refrigerator on [DATE], at 11:20 a.m. revealed opened carrots and celery with no identifed discard date, carrots with a discard date of [DATE], and cheddar cheese with a discard date of [DATE]. The refrigerator was observed to have a dried sticky substance throughout the shelving. There was a free standing fan located on the counter with dust build up on the fan blades. In an interview on [DATE], at 10:50 a.m., the Senior Director of Dining Services stated that the expectation was to have the dry storage area and refrigerator inspected daily by the greenhouse staff for required labeling and to remove expired food times. 28. Pa. Code 201.18(b)(1)(3) Management. 28. Pa. Code 207.2(a) Administrators responsibility.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to notify the resident and resident's representative in writing upon transfer to the hospital for three of 20 sampled residents. (Residents 21, 44, 79) Findings include: Review of the facility policy entitled, Transfer and Discharge Requirements, dated August 2020, revealed that, the Community will notify the resident and the representative of the transfer/discharge and the reasons for the move in writing and in a language they understand. Clinical record review revealed that Resident 21 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) admission assessment dated [DATE], indicated that the resident was oriented and required staff assistance for activities of daily living. Nursing documentation noted that the resident had a fall on January 30, 2021. Nursing notes dated February 1, 2021, stated that the resident's left leg was assessed and observed with the foot rotated outward, leg shorter than the right, and hip area swollen. The resident was transferred to the hospital and admitted with a left hip fracture. There was no documentation to support that the resident or resident representative was given a written notice with required information regarding the transfer to the hospital. Clinical record review revealed that Resident 44 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE], indicated that the resident was able to understand others and was dependent on staff for care. Nursing documentation dated January 13, 2021, noted that the resident was transferred to the hospital and admitted with acute renal (kidney) failure. Additional nursing documentation dated February 10, 2021, stated that the resident was transferred to the hospital for acute kidney injury based on his laboratory (lab) values and admitted for pneumonia and management of abnormal labs. There was no documentation to support that the resident or resident representative was given a written notice with required information regarding the transfers. Clinical record review revealed the Resident 79 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE], indicated that the resident was able to understand others. Nursing documentation dated February 18, 2021, noted that the resident was transferred to the hospital and admitted due to a change in the residents condition. There was no documentation to support that the resident or resident representative was given a written notice with required information regarding the transfer. During an interview on April 29, 2021, at 12:05 p.m., the Nursing Home Administrator confirmed that the facility failed to provide the resident and resident's representative with a written notification regarding transfer to the hospital. 28 Pa. Code 201.29(f) Resident rights.

Based on clinical record review, observation, staff interview, and a review of facility documentation, it was determined that the facility failed to provide adequate supervision to residents at risk for falls and ensure that the environment remained free of accident hazards for two of 19 sampled residents. (Residents 45, 77) Findings include: Clinical record review revealed that Resident 45 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated (MONTH) 31, 2019, indicated that the resident was confused, had memory problems, and required extensive physical assistance of two staff persons for transfer and toileting. The care plan initiated on (MONTH) 29, 2019, identified that the resident was at risk for falls due to impaired mobility and cognition, and was totally dependent on two staff to assist with transfers and toileting. On (MONTH) 17, 2019, at 12:09 p.m., NA1 was observed transferring the resident from the recliner to his wheelchair without the assistance of another staff person. On (MONTH) 19, 2019, at 10:39 a.m., NA 1 was observed transferring the resident out of his wheelchair and walking him into the bathroom without the assistance of another staff person. NA1 did not have a second staff member to assist the resident as indicated by the resident's care plan. Clinical record review revealed that Resident 77 had [DIAGNOSES REDACTED]. Review of incident reports revealed that the resident sustained [REDACTED]. On (MONTH) 20, 2019 at 11:40 a.m., Resident 77 was observed in bed with the an elevated right half side rail. A note dated (MONTH) 29, 2019, indicated that therapy was to reassess the appropriateness of the side rail related to the resident's bruising. There was a lack of documentation to support that the bed rail had been evaluated to ensure the prevention of injury to the resident. In an interview on (MONTH) 20, 2019, at 1:30 p.m., the Administrator confirmed that the bed rail had not been evaluated by the therapy department. CFR 483.25 (d)(1)(2) Accidents. Previously cited 10/12/2018 28 Pa. Code 211.12(d)(1)(5) Nursing Services. Previously cited 10/12/2018

Based on clinical record review and staff interview, it was determined that the facility failed to provide services to restore continence to the extent possible to residents who were incontinent of bladder and/or bowel for two of 19 sampled residents. (Residents 2, 55) Findings include: During an interview on (MONTH) 20, 2019, at 12:08 p.m., the Registered Nurse Assessment Coordinator (RNAC) reported that the facility did not have a restorative bowel and bladder program and that all residents able to use the toilet were assisted in accordance with facility protocol which was upon waking, before and after meals, prior to bed time, and as needed. Clinical record review revealed that Resident 2 was admitted to the facility on (MONTH) 23, 2019, and had [DIAGNOSES REDACTED]. At the time of admission, the resident had an indwelling urinary catheter in place which the physician ordered to be removed on (MONTH) 28, 2019. The Minimum Data Set (MDS) assessment, dated (MONTH) 30, 2019, indicated that the resident had impaired thinking, was frequently incontinent of bladder, and required the extensive assistance of one staff to use the toilet. The urinary tracking sheet indicated that the resident continued to be frequently incontinent through (MONTH) 19, 2019. There was a lack of documentation to support that the resident had been evaluated for services to restore urinary continence. In addition, review of toileting records dated (MONTH) 21, 2019, through (MONTH) 19, 2019, revealed that the resident was not assisted to the toilet in accordance with facility protocol on 30 of 30 days. Clinical record review revealed that Resident 55 was admitted to the facility on (MONTH) 5, 2019, and had [DIAGNOSES REDACTED]. The MDS assessment, dated (MONTH) 4, 2019, indicated that the resident had memory problems, was frequently incontinent of bowel and bladder, and required extensive staff assistance to use the toilet. There was a lack of documentation to support that the resident had been evaluated for services to restore continence. In addition, review of toileting records (MONTH) 21, 2019, through (MONTH) 19, 2019, revealed that the resident was not assisted to the toilet in accordance with facility protocol on 30 of 30 days. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 10/12/18.

Based on clinical record review and review of an incident report, it was determined that the facility failed to provide adequate supervision to a resident who was at risk for falls due to behaviors in order to prevent a fall for one of 18 sampled residents. (Resident 32) Findings include: Clinical record review revealed that Resident 32 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated (MONTH) 13, (YEAR), indicated that the resident was cognitively impaired, exhibited physical behaviors at least one to three days in the assessment period, required extensive assistance for activities of daily living including transfers and had a history of [REDACTED]. Review of nursing documentation dated (MONTH) 16, (YEAR), at 10:33 p.m., revealed that the resident was restless after supper and was repeatedly standing up. When the resident did go to bed, she was repeatedly putting her legs off the side of the bed. On (MONTH) 19, (YEAR), at 9:14 p.m., the resident was seated in the hallway and attempting to stand up unassisted from her chair. On (MONTH) 22, (YEAR), at 12:31 a.m., a nurse noted that the resident had a behavioral outburst in the evening of yelling out and was uncooperative with care. On the same day at 11:21 a.m., a social worker noted that the resident was exhibiting continued behaviors on the unit. On (MONTH) 22, (YEAR), at 11:03 p.m., a nurse noted that the resident had refused most of her at bedtime medications, was combative, and was refusing to go to bed. At that time a nurse noted that she was sitting in her wheelchair dozing in the lounge area of the nursing unit. On (MONTH) 23, (YEAR), at 12:00 a.m., a nurse noted that the resident was sleeping on and off but had refused to go to bed. The nurse further documented that a staff member observed the resident seated in the lounge and then the sat at the computer in nursing station with her back facinglthe lounge. Soon after the staff heard the sound of the wheelchair falling. The nurse noted that the resident was lying on the floor on her right side, there was blood on the floor, and the resident had a laceration to the eye. Review of the facility incident report dated (MONTH) 22, (YEAR), identified that a contributing factor to the fall was that the resident had been combative and restless on the shift and was napping in her wheelchair because she had refused to go to bed. There was no documented evidence to support that the facility had provided the level of supervision necessary to Resident 32 in an effort to prevent a fall from her wheelchair. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facilty failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the resident's status for one of 16 sampled residents. (Resident R41) Findings include: The MDS assessment for Pneumococcal vaccine (Section O) must be completed accurately with quarterly assessments. Clinical record review revealed that Resident R41 had quarterly MDS assessments (Section O) completed on December 27, 2016, March 24, 2017 and June 20, 2017. The MDS assessments failed to identify the resident's allergy to the Pneumococcal vaccine. In an interview on September 22, 2017, at 10:06 a.m., the Registered Nurse Assessment Coordinator confirmed that the assessments were not accurate. 28 Pa. Code 211.15(f) Clinical records.

Based on facility policy and clinical record review, it was determined that the facility failed to provide dental services to meet the needs of one of sixteen sampled residents. (Resident R12) Findings include: Review of the facility policy entitled Oral Care dated July 18, 2017, revealed that residents would receive dental care to maintain healthy teeth and gums, promote comfort and ensure residents are free from dental issues. Clinical record review revealed that resident R12 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had severely impaired cognition and could sometimes make himself understood. On August 14, 2107 at 8:24 p.m., clinical documentation revealed that Resident R12 had broken a tooth while eating supper. On September 15, 2017 at 11:42 a.m., a nutritional assessment states resident had a weight loss and was reported to be taking a long time to chew his foods. There was no documentation to support that the resident had been seen by the dentist to address his dental concerns. 201.14(a) Responsibility of licensee.

Based on clinical record review, it was determined that the facility failed to effectively manage a resident's pain for one of 15 residents reviewed who experienced pain (Resident R55). In addition, based on clinical record review, review of facility policy, and staff interview, it was determined that the facility failed to implement physician's orders [REDACTED]. Findings include: The clinical record review revealed that Resident R55 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On June 5, 2016, at 7:30 a.m. a Licensed Practical Nurse (LPN) noted that the resident was, screaming and crying of pain in lower back and that the [MEDICATION NAME] had been administered with only minimal relief. On June 6, 2016, a Certified Registered Nurse Practitioner (CRNP) noted that the, patient was seen today with ongoing low back pain. Pain is not improved despite the [MEDICATION NAME] every four hours. At that time, the CRNP ordered a CT scan (Computerized Tomography scan, a special computerized X-ray with increased detail) of the lumbosacral spine (lower back) due to, acute onset of pain unrelieved by medication and a history of disc disease. The CT scan was scheduled for June 10, 2016, however the resident continued to experience unrelieved pain in her lower back from June 7 through June 10, 2016. On June 7, 2016, at 9:28 p.m. an LPN noted that the resident, continues to complain of pain and that pain medications were given every four hours with, little relief. On June 8, 2016, at 8:11 a.m. an LPN noted that there was, no change in the relief from pain, and that the, (resident was) crying out and moaning excessively when ambulating (walking) to the toilet, [MEDICATION NAME] was given at 0500. (There was) NO EFFECT for severe lower back pain. An LPN noted on June 8, 2016, at 3:31 p.m. that the resident, complains of constant severe pain, [MEDICATION NAME] two tabs (was) given every four hours. (The resident) states no relief. On June 9, 2016, at 8:15 a.m. an LPN noted that the resident had, severe debilitating pain. The same day at 3:33 p.m. the LPN again noted that the resident had frequent complaints of pain in her back and that [MEDICATION NAME] was given at 9:15 a.m., and 1:45 p.m., for pain with only, some relief noted. On June 10, 2016, at 9:40 p.m. an LPN again noted that the resident, complains of constant excruciating pain and that the as needed [MEDICATION NAME] was administered with no effect. On June 11, 2016, at 1:00 p.m., an LPN noted that the resident stated she had, ongoing severe pain (and) PRN [MEDICATION NAME] (was) given with no effect. The CT scan identified that the resident had a bulging disc. There was no documented evidence that the facility provided care and services to the resident in order to adequately and effectively manage the resident's pain. Review of the facility's policy entitled, Bowel Protocol, dated July 19, 2016, revealed that the staff were to detect poor or irregular function of the bowels in order to intervene promptly and appropriately as per physicians' orders. The clinical record review revealed that Resident R55 also had [DIAGNOSES REDACTED]. On the day of admission, the physician ordered a bowel management protocol that included for the staff to administer Milk of Magnesia (an oral laxative) every third day at noon and as needed; if the resident did not have a bowel movement, a [MEDICATION NAME] suppository (a laxative inserted into the rectum) at 9:00 p.m.; if there were no results from the Milk of Magnesia and a fleets enema (a solution administered into the rectum to stimulate bowel activity) on the 11:00 p.m., to 7:00 a.m., shift if there were no results from the [MEDICATION NAME] suppository. On June 7, 2016 at 8:01 a.m., an LPN noted that an enema was administered at 0730 for bowel management since the (resident) did not move her bowels for four days. Review of the bowel movement records revealed that the resident did not have a bowel movement for three days between June 4, and June 6, 2016; however, there was no documented evidence that the facility followed the physician order [REDACTED]. An interview on October 27, 2016, at 2:12 p.m. with the Nursing Home Administrator confirmed that the facility failed to implement the bowel management protocol in accordance with the physcian's orders. CFR 483.25 Quality of Care Previously cited 9/18/15 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 9/18/15

Based on clinical record review, it was determined that the facility failed to provide adequate supervision and assistance to one of 13 residents reviewed who were at risk for falls (Resident R55) and failed to prevent an elopement for one of three residents reviewed who were at risk for elopement (Resident R40). In addition, based on observations, the facility failed to ensure that the residents' environment was free of accident hazards on one of six nursing units (the Leffler Care Center nursing unit). Findings include: Clinical record review revealed that Resident R55 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On June 25, 2016, a nurse noted that the resident had been found lying on her back at 12:29 a.m. beside her bed with her walker tipped over. On this same day, a nurse noted that the resident was admitted to the hospital with [REDACTED]. Review of the facility's investigation report dated June 25, 2016, revealed that there were no new interventions for the resident's safety, other then a physical therapy evaluation, once the resident returned from the hospital in order to prevent future falls. On June 28, 2016, a nurse noted that the resident was returned to the facility from the hospital. On the same day at 7:27 p.m. a nurse noted that the resident had been found on the floor at 5:15 p.m., and was again sent out of the facility and admitted to the hospital with [REDACTED]. Review of the event report dated June 28, 2016, revealed that the resident needed some physical support while walking. The report also indicated that a staff member had, just set her up for her meal and left the resident's room. Shortly after leaving the room, a loud thud was heard and the resident was found lying face down on the floor in her room. The resident also sustained a laceration (a cut in the skin) above her left cheek, an ecchymotic area (bruising) on the left side of her neck and her left knee, and a skin tear was noted on her left cheek. There was no documented evidence that the facility had implemented adequate safety measures in order to prevent falls that resulted in injuries. Clinical record review revealed that Resident R40 had [DIAGNOSES REDACTED]. Review of an elopement (leaving the facility unsupervised) risk evaluation dated June 1, 2016, indicated that the resident was at risk for elopement because she independently walked, was disoriented and had a [DIAGNOSES REDACTED]. On July 7, 2016, a nurse noted at 7:29 p.m. that a nursing aide found the resident off the nursing unit down a hallway and that the resident stated, she was looking for something to do. The note further indicated that the resident had been at the nursing desk prior to the elopement for the previous hour looking for an activity because an activity had been cancelled. On July 8, 2016, a physcian ordered that staff apply a Wanderguard (a bracelet to alert staff of attempts to leave the nursing unit). Review of an elopement risk evaluation dated July 8, 2016, revealed that the resident had made one or more attempts to leave the unit and was wandering, trying to go home, and remained an elopement risk. On July 22, 2016, a physician ordered that the staff discontinue the Wanderguard due to no further attempts to leave the unit; however, on July 21, 2016, at 2:15 p.m. and again on July 24, 2016, at 2:01 p.m. a nurse noted that the resident had exhibited wandering behavior. On August 7, 2016, at 3:05 p.m. a nurse noted that the resident had been found off of the nursing unit near the reception desk and that the resident was trying to find an activity. The facility failed to adequately supervise Resident R40 who was at risk for elopement from leaving the nursing unit without the knowledge of the staff. Observation on the Leffler Care Center nursing unit on October 28, 2016, at 10:32 a.m., 11:19 a.m. and 12:30 p.m. revealed that the door was open to the central bathing area. On the bathroom vanity, there were six nail clippers, two packs of disposable razors, and a container of shaving cream that indicated to keep out of reach of children due to the contents. These items were accessible to confused, mobile residents who resided on the Leffler Care Center nursing unit. In addition, on October 25, 2016, at 11:17 a.m., on October 26, 2016, at 10:00 a.m. and again on October 27, 2016, at 9:45 a.m. a pair of scissors was observed on top of the medication cart. The scissors were accessible to confused, mobile residents who resided on the Leffler Care Center nursing unit. Additionally, on October 28, 2016, at 11:19 a.m. the clean utility rooms that were located on all three hallways of the Leffler Care Center nursing unit were observed unlocked. There were cabinets that were also unlocked and contained multiple personal hygiene items that included body wash/shampoo, protective ointments and creams, shaving cream, mouthwash, deodorant and denture cleanser tablets. In an interview on October 28, 2016, at 10:00 a.m. the Nursing Home Administrator stated that there were three confused, mobile residents who resided on the Leffler Care Center nursing unit (Residents R40, R74 and R76) CFR 483.25(h) Accidents. Previously cited 9/18/15 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 9/18/15

Based on clinical record review, it was determined that the facility failed to ensure that a resident's responsible party was notified of significant changes of medical status in a timely manner for one of 20 residents reviewed (Resident R57). Findings include: Clinical record review revealed that Resident R57 had [DIAGNOSES REDACTED]. Review of nursing documentation dated April 14, 2016, revealed that the resident had complained of a sore throat, was coughing and had a high body temperature. That same day, a nurse noted that she heard crackles (course abnormal breath sounds) at the base of the resident's lungs. The nursing notes dated April 17, 2016, indicated that the resident still had a high body temperature, continued with a moist cough, had some scattered wheezes (high pitched abnormal breath sounds) and diffuse course lung sounds. That same date, a physician ordered that the staff administer [MEDICATION NAME] (a breathing treatment) every six hours as needed for cough and congestion and ordered a chest X-ray if the resident continued to have an elevated temperature. On April 18, 2016, at 3:57 p.m. a nurse noted that the chest X-ray was completed and the resident was diagnosed with [REDACTED]. from April 14, 2016, until April 18, 2016, at 11:12 p.m. On April 29, 2016, at 11:10 p.m. a Registered Nurse (RN) noted that Resident 57 had experienced a fall that resulted in an abrasion (a wound caused by scraping) on the left side of her head. There was no documented evidence that the resident's responsible party was notified of the fall or the injury until May 1, 2016, at 11:01 a.m. 28 Pa.Code 211.12(d)(1)(5) Nursing services. Previously cited 9/18/15

Based on clinical record review and staff interview, it was determined that the facility failed to implement a care planned intervention for one of 20 residents reviewed (Resident R76). Findings include: The clinical record review revealed that Resident R76 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs) dated June 3, 2016, indicated that the resident had cognitive impairment and signs of [MEDICAL CONDITION] (a state of mental confusion) that included inattention and disorganized thinking. The MDS also indicated that the resident experienced wandering behaviors and was able to walk on the nursing unit with the assistance of a walker. Review of the current care plan (a document that lists resident's care needs and the measures that staff were to implement to meet those needs) revealed a problem area which identified that the resident was at risk for elopement (leaving the facility unsupervised). On June 27, 2016, an intervention was added to the care plan for the staff to monitor the resident for safety every thirty minutes. The staff were to complete resident, Safety Monitoring Logs and document safety checks on the resident every thirty minutes due to the resident's ongoing risk for elopement. Review of the safety monitoring logs between August 5 and October 22, 2106, revealed omissions on various times of the day and night (August 5, August 8, August 10, August 16, August 19, September 6, September 10, September 25, October 8, 2016 blank during day shift; October 4, 2016 blank 3PM-4:30 PM, October 9, 2016 blank 12 AM-6:30AM, and October 5, October 15, and October 20, blank all day) for a total of 14 days when there was no documented evidence that the staff had completed the thirty minute safety checks. During an interview on October 28, 2016, at 10:00 a.m. the Nursing Home Administrator confirmed that the facility failed to consistently document the thirty minute safety checks and did not implement the care planned intervention. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 9/18/15

Based on clinical record review and staff interview, it was determined that the facility failed to assess a decline in urinary continence and provide care to restore bladder function for one of 15 residents reviewed with urinary incontinence (Resident R55). Findings include: The clinical record review revealed that Resident R55 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs) dated June 9, 2016, indicated that the resident was occasionally incontinent of bladder (unable to control her urination) and required assistance from staff for most activities of daily living (ADL- routine daily functions most people do without assistance) that included getting out of bed, using the toilet, bathing and grooming. Review of MDS assessments dated July 18, 2016, and October 13, 2016, revealed that the resident's bladder status had declined to being frequently incontinent of bladder. The assessments also indicated that the resident continued to require assistance from the staff for the same ADL care. There was no documented evidence that the facility had assessed the decline in the resident's bladder incontinence to provide appropriate care and services in order to restore as much bladder function as possible. In an interview on October 28, 2016, at 12:58 p.m. with the Nursing Home Administrator, it was confirmed that the decline in the resident's bladder incontinence had not been assessed in order to restore as much bladder function as possible. 28 Pa.Code 211.12(d)(1)(5) Nursing services Previously cited 9/18/15

Based on observation and a review of previous staffing data postings, it was determined that the facility failed to post the actual number of staffing hours by category per shift. Findings include: During a tour of the facility conducted on October 25, 2016, at 10:15 a.m. the staffing information was posted at the receptionist desk. The posting did not include the total number of actual hours worked for staff members by category (registered nurses, licensed practical nurses, and nurse aides). Review of previous staffing data postings from April 4 through 10, 2016, October 3 through 9, 2016, and October 22 through 26, 2016, revealed the nursing staffing that was posted did not include the total number of actual hours worked for staff members by category.

Based on clinical record review, facility documentation, staff interview, and observation, it was determined that the facility failed to adequately supervise a resident to prevent an elopement for one of two resident's sampled at risk for elopement. (Resident R54) Additionally, the facility failed to ensure that the resident's environment was free of safety hazards one of six nursing units. (Tranquil Terrace) Findings include: Clinical record review revealed that Resident R54 had [DIAGNOSES REDACTED]. A elopement risk assessment dated [DATE], identified the resident at risk for elopement. The Minimum Data Set assessment dated [DATE], noted that the resident was cognitively impaired, had wandering behavior, required assistance with transfers but was able to independently propel her wheelchair as a means of locomotion. Review of the nursing documentation from December 11, 2014, through September 15, 2015, revealed that the resident had exit seeking behaviors consistent with wanting to go home, looking for her car, and frequently banging on the main exit door. On September 15, 2015, at 1:55 p.m., the resident was observed at the front door stating I'm going to go home and self propelling towards the front door. In an interview on September 17, 2015, at 10:30 a.m., the Environmental Services Director and the Maintenance Supervisor stated that the electronic door system malfunctioned on August 12, 2015, in all four greenhouses. The system allowed the doors in all the greenhouses to open with a staff identified swipe card. When the system malfunctioned all doors were locked for entry and exit. Maintenance staff had to pull the fuse on the doors that released the lock to allow exit from the greenhouse. No further safety interventions were done until August 18, 2015, when a door alarm was applied. On August 17, 2015, at 2:30 p.m., Resident R54 was found outside on the ground across the street. Review of facility documentation revealed that the three nursing staff in the greenhouse (Royer) were all in resident rooms providing care at the time that Resident R54 was found. There was a lack of evidence to support that staff provided adequate supervision to prevent the resident from leaving the greenhouse without staff knowledge. On September 17, 2015, at 12:55 p.m., the Director of Nursing stated that there was no documentation that the facility increased the level of staff supervision for the residents or provided temporary door safety interventions after the doors malfunctioned on August 12, 2015, and prior to the resident's elopement on August 17, 2015. Additionally, the care plan developed after the elopement identified that the resident's location was to be checked every 30 minutes. There was no documentation that the facility completed any 30 minute checks. Observations during an environmental tour on September 17, 2015, at 1:50 p.m., on Tranquil Terrace (the 18 bed secured unit for cognitvely impaired residents) revealed one spray bottle of a cleaning product (Oasis 146 Multi Sanitizer) unattended in the open kitchen area and accessible to residents. The product label indicated that the cleaning product was hazardous to humans and animals and causes irreversible eye damage and skin burns. Further observation on September 18, 2015, at 11:35 a.m., revealed a spray bottle of cleaning product (Oasis 146 Multi Sanitizer) in a cabinet under the sink in the kitchen area on Tranquil Terrace and the cabinet was unlocked and accessible to residents. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 10/3/14

Based on clinical record review and staff interview, it was determined that the facility failed to revise a comprehensive care plan that addressed the current needs for one of 19 sampled residents. ( Resident R54) Findings include: Clinical record review revealed that Resident R54 had [DIAGNOSES REDACTED]. The February 10, 2015, Minimum Data Set assessment indicated that the resident wandered. Review of the nursing documentation since December 11, 2014, through the time of the survey revealed that the resident had numerous episodes of exit seeking behavior. A Elopement Risk assessment was completed May 6, 2015, that indicated that the resident was at risk for elopement with a score of five. There was a lack of evidence that the comprehensive care plan was revised to include the resident's risk for elopement. On September 17, 2015, at 2:55 p.m., the Director of Nursing stated that a care plan was to be developed when a score of one or greater was obtained. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/3/14

Based on clinical record review and staff interview, it was determined that the facility failed to obtain laboratory services in accordance with physician orders [REDACTED]. (Resident R21) Findings include: Clinical record review revealed that Resident R21 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The physician ordered laboratory studies including a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) as a result of the assessment. There was no evidence that these studies had been completed. In an interview on September 17, 2015, at 11:10 p.m., the Director of Nursing stated that the laboratory studies had not been completed as nursing staff had failed to schedule the tests with the laboratory. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 10/3/14 28 Pa. Code 211.12(d)(3) Nursing services.

Based on observation of the medication pass on three of six nursing units and clinical record review, it was determined that the facility had a 6.45 percent error rate from 31 observed medication pass opportunities. (Lefler unit) Findings include: Observation of the medication pass on September 16, 2015, at 8:25 a.m., revealed that LPN1 made the following error when administering medication to Resident R50. [MEDICATION NAME] ( a respiratory inhaler for shortness of breath ) had instructions from the manufacturer to rinse mouth after use and spit. LPN1 failed to have the resident rinse his mouth and spit after administration of medication. Observation of the medication pass on September 16, 2015, at 8:30 a.m., revealed that LPN2 made the following error when administering medication to Resident R21. Resident R21 had physician's orders [REDACTED]. During observation of the medication pass LPN2 administered only one drop to each of the resident's eyes. 28 Pa. Code 211.12(d)(5) Nursing Services Repeat deficiency 10/03/14