Every finding on record at LECOM at Asbury Ridge dba Saint Mary's Asbury Ridg

Based on observations and staff interviews, it was determined that the facility failed to label multi-dose containers of Tuberculin solution (used to test for the disease tuberculosis) with the date they were opened in one of two medication storage rooms. Findings include: Observation on 9/10/25, at 10:15 a.m. of a medication storage refrigerator revealed an opened and undated multi-dose vial of Tuberculin solution. During an interview on 9/10/25, at 10:20 a.m. Licensed Practical Nurse Employee E1 confirmed that the multi-dose vials of Tuberculin solution should have been labeled with the date it was opened. During an interview on 9/10/25, at 10:35 a.m. the Director of Nursing confirmed that the multi-dose vials are labeled to discard after 30 days opened and that staff would not be able to determine when to discard the vials due to the lack of an opened date. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of the hospice/facility agreement and clinical records, and staff interview, it was determined that the facility failed to maintain current information related to Hospice services for one of three residents reviewed (Closed Record Resident CR1). Findings include: A Hospice Care Services Agreement dated 2/08/06, indicated that, Hospice shall communicate with facility to ensure coordination of patient care services; Hospice Health Aides shall provide a copy of the completed assignment form to the facility; facility and Hospice each shall prepare and maintain records concerning patients receiving services under this agreement; and such records shall be available for review and inspection by each party as necessary for the treatment of patients under this agreement. Resident CR1's clinical record revealed an admitted [DATE], with diagnoses that included senile degeneration of the brain (irreversible memory loss, behavioral and cognitive decline, personality changes, and a decreasing ability to cope with everyday life), encounter for palliative care (indicates that a patient's goals are comfort-oriented), mood disorder, difficulty swallowing. A care plan initiated 9/01/23, indicated the need for Hospice care due to the terminal condition of senile degeneration of the brain. Further review of Resident CR1's clinical record revealed a revocation of Hospice services dated 8/19/24, and a provider progress note dated 8/20/24, that indicated the discontinue of Hospice services. Resident CR1's clinical record contained Hospice communication documents with a visit date of 6/18/24, and there was no evidence of Hospice communication sheets beyond 6/18/24. During an interview on 1/06/25, at 12:06 p.m. the Director of Nursing confirmed there was no evidence of Hospice communication documents for Resident CR1 between 6/18/24, and 8/19/24, (date Hospice services were revoked). 28 Pa. Code 201.14(a)(b) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(f)(iii)(viii)(ix) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of PAHAN 694, and resident and staff interviews, it was determined that the facility failed to provide care in a manner that maintained the resident's psychosocial well-being for six of 24 residents reviewed (Residents R68, R26, R53, R56, R57, and R65). Findings include: Review of the 2023 PAHAN 694 5-11-UPD UPDATE encourages the use of masks until no new cases of SARS-CoV-2 infection have been identified for 14 days. From 11/27/23, through 11/28/23, during resident interviews, the following residents complained of an inability to communicate with masked staff members: During interview on 11/27/23, at 11:10 a.m. Resident R68 expressed frustration with difficulties communicating with staff members as their masks inhibited the resident's ability to hear what the staff were saying to them. During interview on 11/27/23, at 1:35 p.m. Resident R26 complained that on several occasions they avoided communicating with staff as it was too hard to understand what the staff were saying while they were wearing masks and wasn't worth the trouble. During interview on 11/27/23, at 2:15 p.m. Resident R53 disclosed that it was difficult to communicate with the staff due to their wearing masks and that they were made to feel as though the staff were afraid that they had some sort of a disease. During interview on 11/28/23, at 11:20 a.m. Resident R56 indicated he/she could not hear conversation and was noted with confusion about the mask being worn; making motion to remove mask. During interview on 11/27/23, at 2:30 p.m. Resident R57 indicated he/she asks staff to repeat themselves several times and eventually requests staff to pull the mask down so he/she can understand conversation. During interview on 11/27/23, at 3:00 p.m. Resident R65 indicated he/she has a difficult time hearing staff and consistently asks them to repeat themselves and/or pull the mask down to understand and hear what they are saying. During interview on 11/27/23, at 4:00 p.m. Nursing Staff Employee E5 revealed that it was very difficult' to communicate with residents while wearing a mask. During interview on 11/28/23, at 1:20 p.m. Nursing Staff Employee E6 confirmed that the residents had a difficult time understanding the staff while wearing masks. During interview on 11/30/23, at approximately 11:50 a.m. the facility's President, Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the staff were made to wear masks at all times in the resident areas. They also indicated that they were using the 2023 PAHAN 694 5-11-UPD UPDATE (PENNSYLVANIA DEPARTMENT OF HEALTH 2023 PAHAN 694 5-11-UPD UPDATE: Interim Infection Prevention and Control Recommendations for COVID-19 in Healthcare Settings) to determine whether staff should be made to wear masks. During interview on 11/30/23, at approximately 11:50 a.m. the facility's President, NHA, and DON confirmed that there had been no new cases of SARS-CoV-2 infection for at least 35 days, revealing that the last case had been identified on 10/26/23. 28 Pa. Code 201.29(a) Resident rights

Based on review of facility policies and clinical records, observations, and staff and resident interviews, it was determined that the facility failed to follow physician's orders in accordance with standards of practice regarding respiratory care equipment for one of 18 residents reviewed (Resident R11). Findings include: Review of a facility policy entitled Oxygen Administration dated 5/23/23, revealed, O2 [oxygen] tubing is to be changed weekly, Sunday on 11pm-7 am shift by nursing and as needed humidifier bottle changed weekly. Review of a facility policy entitled Administering Medications Through a Small Volume (Handheld) Nebulizer [medical device to administer medications for respiratory conditions] dated 5/23/23, revealed, Nurse to change equipment and tubing every Sunday (11pm - 7am shift). Review of Resident R11's clinical record revealed an admitted [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD-a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing and shortness of breath), Congestive Heart Failure (CHF - a progressive heart disease that weakens the pumping action of the heart muscles, causing fatigue and shortness of breath in the resident), and Permanent Atrial Fibrillation (A-Fib - a type of abnormal, rapid heartbeat that is present all the time, causing shortness of breath, heart palpitations, weakness and can lead to development of blood clots). Review of R11's clinical record revealed physician's orders dated 11/18/23, that identified the use of oxygen through a nasal canula (tubing with prongs inserted to the nostrils that deliver oxygen into the resident's nostrils) and physician's orders for nebulizer treatments as needed for shortness of breath, wheezing. Observation on 11/28/23, at 10:25 a.m. revealed that Resident R11's oxygen nasal canula and oxygen humidifier bottle did not have dates identified to indicate when they were last changed. Further observation revealed Resident R11's slow-volume (handheld) nebulizer device that also did not have a date when it was last changed. During an interview on 11/28/23, at 10:30 a.m. Resident R11 indicated that staff have not replaced the oxygen humidifier, nasal canula, or nebulizer device and tubing weekly. During an interview on 11/29/23, at 10:02 a.m. the Infection Control Nurse confirmed that Resident R11's oxygen nasal canula, humidifier bottle, nebulizer device, and tubing all did not have a date to identify when they had been changed according to physician's orders and that all the items should be dated when changed by staff. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies, review of manufacturer recommendations, observations, and staff interviews, it was determined that the facility failed to store food in accordance with professional standards and to maintain dish machine water temperatures in accordance with manufacturer recommendations for food service safety in the main kitchen. Findings include: Review of the facility policy entitled, Dietary Infection Control, dated March 1999, with a policy review date of 1/17/22, indicated, it is the policy of the facility to maintain infection control measures to prevent cross contamination or infection. Guidelines must be followed for proper refrigeration of food items before, during, and after preparation procedures. Review of the facility policy entitled, Food Storage Procedures, dated October 2000, with a policy review date of 1/17/22, indicated, It is the policy of the facility that food products are dated with the date received and the placed in the temperature climate area based on the food product. All items in refrigerators, freezers, and storerooms are dated with the date received. The items with the oldest dates shall be used first. All leftovers and pre-portioned foods in the refrigerators are dated and used within 3 days. Review of Manufacturers Recommendations revealed that the wash cycle of the machine should reach 160 degrees and the rinse cycle should reach 180 degrees Farenheit (F). Observations of the kitchen on 11/15/22, at 12:35 p.m. in the walk-in refrigerator revealed two pans of soup sitting in the refrigerator uncovered and undated. An interview with Dietary Manager at the time of the observation, confirmed that the pans of food should be covered and dated when stored in the refrigerator for sanitary purposes. Review of the facility policy entitled, Warewashing, revised September 2017, indicated that all dishware, serviceware, and utensils will be cleaned and sanitized after each use. The Dining Services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware. All dish machine water temperatures will be maintained in accordance with manufacturer recommendations for high temperature or low temperature machines. Temperature and /or sanitizer concentration logs will be completed, as appropriate. All dishware will be air dried and properly stored. Attachment: Dish Machine Log revealed Dish Machine Temperatures were to be taken after Breakfast, Lunch and Dinner. Standards: High Temperatures: Wash cycle: 150-160 degrees Fahrenheit and Rinse cycle: 180 degrees Fahrenheit. If temperature does not meet parameters, stop washing and alert a manager or designee. During observations on 11/15/22, at 12:45 p.m. of the dish washing machine temperature accompanied by the Maintenance Director Employee E4, it was revealed that the wash cycle temperature reached 136 degrees F on one cycle and on another cycle was 140 degrees F and the rinse cycle with a temperature of 196 degrees F. Dishes and serviceware were removed from the rack and placed in a clean area to air dry. Observation of the dishwashing machine revealed manufacturer's information on the machine to identify that the temperature for the wash cycle should reach 160 degrees F and the rinse cycle should reach 180 degrees F. Interview with the Dietary Manager during the observation, confirmed that the wash cycle was reading low, and he/she was unaware that the wash cycle was not properly reaching the 160 degree F level consistently and that the maintenance staff should be called to fix the temperature of the wash cycle. Review of Dish Machine Temperature Logs for November 2022 revealed that in the month of November, the temperature for the wash cycle never met 160 degrees from November 1 through November 15 with a range of 147-159 degrees F for breakfast and 146-156 degrees F for dinner. Temperatures were not recorded at breakfast on 11/1/22, 11/5/22, 11/6/22, 11/10/22. Lunch temperatures were not recorded for the whole month, and dinner temperatures were not recorded on 11/5/22 and 11/6/22. The wash temperatures are written on the log sheet and were to reach 160-170 degrees F, and the rinse temperatures to reach 180-190 degrees F. The bottom of the log sheet indicated, when temperatures are not within acceptable ranges, report this to the supervisor immediately and document the date and time that you informed the supervisor on the back of the form. There was no documented evidence that the manager/designee was alerted or a work order was initiated. 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 28 Pa. Code 201.18(e)(1) Management

Based on a review of facility policy and clinical records and staff interview, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of the five residents reviewed for unnecessary medications (Resident R12). Findings include: Review of facility policy entitled, Aggressive Behavior, dated 1/07/22, indicated that Nursing personnel learn the Resident's likes and dislikes, communication style, past behavioral symptoms, preferred routines, and habits. Personnel learn at least three things that give the Resident comfort, e.g., doll, telephone call to relative, back rub, etc. The nursing staff will implement a plan of care which will enable the staff to care properly for the aggressive resident and assure that his/her needs are being met. Review of Resident R12's clinical record revealed an admitted [DATE], with diagnoses that included history of urinary tract infection, anxiety, Alzheimer's disease (a disease of the brain that affects decision making, mood and behaviors), and vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to regions of the brain). The clinical record revealed that on 9/08/22, Resident R12's physician ordered Lorazepam (medication ordered to treat anxiety) 0.25 milligrams (mg) by mouth every four hours PRN for anxiety. Review of Resident R12's care plan, dated 1/03/22, indicated an intervention for the Use of Ativan for anxiety-Areas of concern and feelings of anxiety will be discussed, and emotional support provided prior to giving Ativan and document . Review of Resident R12's Medication Administration Record (MAR) for October and November 2022 revealed the PRN Lorazepam was used on 10/25/22 and 11/17/22. There was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Lorazepam for two of the two times the Lorazepam was administered in October and November 2022. During an interview on 11/18/22, at 10:41 a.m. the Director of Nursing confirmed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Lorazepam two of the two times it was administered between 10/25/22 and 11/18/22, for Resident R12. 28 Pa. Code 211.12(d)(1)(3(5) Nursing services

Based on review of the manufacturer's recommendations, observations, and staff interviews, it was determined that the facility failed to ensure the medications were properly dated when opened for one of three medication rooms (Unit E). Findings include: Review of manufacturer's recommendations for Tubersol (medication used for tuberculosis testing) revealed that if a vial of Tubersol which has been entered and in use for 30 days should be discarded. Observation of the refrigerator in the Unit E medication room on 11/17/22, at approximately 12:45 p.m. revealed an open vial of Tubersol that did not have an open date, therefore staff was unable to determine the discard date. During an interview at the time of the observation, Registered Nurse Employee E1 confirmed that the Tubersol did not have an open date and that it should have been dated upon opening to ensure it could be properly discarded after 30 days. During an interview on 11/17/22, at approximately 1:30 p.m. the Director of Nursing confirmed that the vial of Tubersol should have been dated upon opening. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical record and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 20 residents reviewed (Resident R50). Findings include: Review of a facility policy dated 6/3/21, entitled Resident / Person Centered Care Planning indicates .Each Resident has a Person-Centered Care plan that is current, individualized and consistent with the medical regimen. Review of Resident R50's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked evidence that a care plan had been developed to address Resident R50's oxygen therapy. During an interview on 1/11/21, at 3:48 p.m. Registered Nurse Employee E2 confirmed that a care plan had not been developed to address Resident R50's usage of oxygen 28 Pa. Code 211.11(d) Resident Care Plan 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to serve food to residents in a sanitary manner during the lunchtime meal in one of two dining areas (E Dining Room). Findings include: Review of facility policy entitled Dietary Infection Control with a revision date of April 2021, stated When handling ready to eat food directly, disposable gloves must be worn by food preparers and servers. Proper hand washing is vital to proper food handling. Observation of lunchtime food service on 1/10/22, at approximately 12:15 p.m. revealed the following in the E Dining room area: Dietary Aide (DA) Employee E3 was serving food in the dining area. With gloved hands, DA Employee E3 left the serving area to get additional food from the hot box, proceeded to touch the handle while wearing the same gloves, remove the food from the hot box, and close the door. DA Employee E3 proceeded to put the food into the steam table. Without removing/changing gloves, DA Employee E3 proceeded to reach into the bread bag remove two pieces of bread and make a sandwich for a resident. On another occasion during the same dining observation, DA Employee E3, came from behind the serving area, touching the handle of a serving cart with gloved hands to check a food order slip of a resident, then proceeded to take bread from the bread bag and make a sandwich for a resident, touching the bread with contaminated gloves. During an interview on 1/10/22, at 12:40 p.m. the Director of Food Services confirmed the above observations and that DA Employee E3 touched food with contaminated gloves. 28 Pa. Code 211.6(c) Dietary services

Based on observations, review of facility policies, clinical records, and Pennsylvania Department of Health Guidance and staff interviews, it was determined that the facility failed to appropriately perform hand hygiene during a wound dressing change for one of eighteen residents (Resident R29) and failed to prevent possible cross contamination related to a catheter (tube placed into the bladder to facilitate urination) for one of 18 residents (Resident R42) and failed to follow infection control protocol regarding the use of wearing N-95 (filtering facepiece respirator) masks while working in designated potential quarantined rooms for COVID-19 for one of eight residents (Resident R4). Findings include: The Pennsylvania Department of Health 2020-PAHAN-530-10-07 ADV, Long Term Care Facility Guidance for Testing and Cohorting: Response to an Outbreak and Residents with Exposure to COVID-19 dated 10/07/20, revealed that a resident under observation or quarantined would be placed in a Yellow Zone (quarantined or observation rooms of residents that are new admissions/readmissions or were out of the facility for a medical reason). Full personal protective equipment (gown, gloves, goggles or face shield, N-95 mask) must be used to care for residents that have been potentially exposed. Observation on 2/16/21, at 3:47 p.m. revealed a staff person entering Resident R4's room, designated as a quarantined Yellow Zone room. The staff was observed wearing a surgical mask and face shield and donning a gown to enter the room. The staff person did not utilize an N-95 mask. The facility had eight residents that were designated as quarantined in Yellow Zone rooms at the time of the survey. During an interview on 2/16/21, at 4:06 p.m. Nurse Aid (NA) Employee E7 and Activity Employee E8 confirmed that the facility did not require the staff to utilize an N-95 mask when entering a quarantined Yellow Zone room. During an interview on 2/16/21, at 4:10 p.m. NA Employee E9 confirmed that the use of the N-95 mask was discontinued a few weeks ago and since then the staff were wearing surgical masks with face shields instead of the N-95 mask with face shields in all the rooms since there were no COVID-19 positive residents currently at the facility. During an interview on 2/17/21, at 3:17 p.m. the Nursing Home Administrator and Director of Nursing verified that beginning on 1/8/21, staff were not required to wear N-95 masks in the Yellow Zone rooms. The facility policy dated 4/06/20, entitled Applying a Clean Dressing indicated that following the cleansing of a wound, gloves are to be removed and discarded and hands washed or sanitized with an alcohol-based hand cleaner before applying clean gloves and any ordered wound treatment and dressing. Resident R29's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R29's physician orders [REDACTED]. Observation of wound care on 2/18/21, at 8:55 a.m. revealed that Registered Nurse (RN) Employee E2 proceeded to cleanse Resident R29's butt wound with gauze dampened with normal saline and a gloved hand. Following the cleansing, RN Employee E2 then removed his/her gloves, and without the benefit of hand sanitization or washing, applied clean gloves and proceeded to apply Triad paste to the wound. At the time of the observation RN Employee E2 confirmed that he/she didn't perform hand hygiene after removing his/her potentially soiled gloves and applying clean gloves. Resident R42 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The 1/20/21 physician order [REDACTED]. Observation on 2/17/21, at 2:45 p.m. revealed Resident R42 lying in bed with the bed in low position. The urinary catheter bag was hung on the lower rail of the bed with the lower part of the catheter bag lying directly on the floor causing a potential for contamination. During an interview on 2/17/21, at 3:00 p.m. RN Employee E6 confirmed that Resident R42's urinary catheter bag was on the floor and was unaware of this being an unsanitary practice and potential source of contamination. Repeat state deficiency 483.80 Infection control 12/04/20 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b) (1) (e) (1) Management 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (d) (1) (3) (5) Nursing services

Based on review of clinical records and the Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User Manual (directions for guidance to complete the Minimum Data Set (MDS-period review of resident care needs) and staff interview, it was determined that the facility failed to correctly code the MDS for one of 18 residents (Resident R42). Findings include: The Long Term Care Facility RAI 3.0 User Manual, dated October 2015, revealed under Section N (Medications) of the MDS and Subsection N0410E, Anticoagulant (e.g., [MEDICATION NAME], or low- molecular weight [MEDICATION NAME]): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications . Resident R42 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Resident R42 had been taking the medication since 5/11/20, when the medication was originally ordered. The Annual MDS, dated [DATE], and the Quarterly MDS completed on 1/15/21, revealed that Section N (Medications), Subsection N0410E (medications received in the seven days of the look back period) were not coded to include Resident R42 was taking an anticoagulant. The December 2020 Medication Administration Record [REDACTED]. During an interview on 2/18/21, at 11:01 a.m. the Registered Nurse Assessment Coordinator Employee E6 confirmed that Resident R42's MDSs were not coded correctly to include the anticoagulant use. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing service

Based on observations, review of clinical records and facility policy and staff interview, it was determined that the facility failed to update a care plan to accurately reflect one of 18 resident's current condition (Resident R29). Findings include: The 4/06/20, facility policy entitled Interdisciplinary Care Conference Guide revealed that resident care plans are reviewed at the Interdisciplinary Care Conference using an interdisciplinary approach to resident care and are updated on an ongoing basis contingent on the resident's condition and care needs. Resident R29's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. Resident R29's care plan, initiated on 12/02/20, and last updated 1/19/21, indicated that Resident R29 had an unstageable (unable to determine the depth due to a covering over the wound bed) pressure ulcer of the coccyx (tailbone). Clinical documentation related to Resident R29's pressure ulcer revealed that on 12/01/20, an unstageable pressure ulcer of the coccyx was identified, measuring 3.0 centimeters (cm) by 0.5 cm, with the base of the wound covered with slough (dead tissue). On 12/10/20, Resident R29's pressure ulcer of the coccyx was assessed to be large, measuring 7.0 cm by 4.5 cm and now a Stage II. A 12/21/20 note, reflected the wound to the coccyx to be healing . now appears to be closed with MASD (moisture associated skin damage - inflammation of the skin from prolonged exposure to moisture such as urine, stool, perspiration, wound drainage). On 12/30/20, clinical documentation indicated that Resident R29 was identified to have an unstageable wound ot the left buttock (butt) measuring 2.0 cm by 1.5 cm by 0.1 cm with slough in the base. Documentation indicated the wound of the left buttock healed on 1/18/21, but re-occurred/re-opened on 2/14/21, assessed as a Stage II, measuring 1.0 cm by 1.4 cm by 0.1 cm, with a moist, red wound bed. Observations of Resident R29's pressure ulcer on 2/18/21, at 8:55 a.m., revealed a small Stage II pressure ulcer to the left, central buttock. During an interview on 2/19/21, at 9:30 a.m. the Director of Nursing confirmed that the care plan was not revised to reflect the current status of Resident R29's pressure ulcer. 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.11(e) Resident care plan

Based on observations, review of clinical records, and staff interview, it was determined that the facility failed to obtain an order from the physician to utilize a positioning device for one of 18 residents (Resident R43). Findings include: Resident R43's clinical record revealed an admission date of [DATE], and readmitted to the facility on [DATE], after a two day hospital admission, with [DIAGNOSES REDACTED]. Observation on 2/18/21, at 11:05 a.m. revealed Resident R43 seated in a wheelchair with multi-podus (special foot device) positioning devices placed on both lower extremities. There was no evidence that the physician ordered the multi-podus positioning devices for Resident R43 from the 2/09/21 physician orders [REDACTED]. During an interview on 2/18/21, at 11:27 a.m. Registered Nurse Employee E2 confirmed that there was not a current physician order [REDACTED]. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents with limited range of motion received appropriate positioning equipment for one of five residents reviewed (Resident R29). Findings include: Resident R29's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The clinical record included an Occupational Discharge Order, dated 1/04/21, and signed by the physician on 1/05/21, for Resident R29 to be up in a Dyna-scoot chair (a positioning chair designed to enhance safe propelling of the chair with the feet) for all meals, for a foot buddy (a support device for a chair that prevents feet from slipping off the foot rests) to be on the chair at all times and to not remove, and for a right lateral support. Observations on 2/17/21, at 12:54 p.m. and on 2/18/21 at 12:00 p.m. revealed Resident R29 up in a Dyna-scoot chair without a foot buddy in place and with regular foot/leg rests on the chair. During an interview on 2/18/21, at 1:34 p.m. Physical Therapist Employee E1, indicated that Resident R29 was to have the Dyna-scoot chair with foot buddy and right lateral support whenever out of bed, that the foot buddy wasn't in place or in the room. During an interview on 2/19/21, at 9:03 a.m. the Nursing Home Administrator confirmed that Resident R29's foot buddy was not in use as ordered. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, review of clinical records and facility policy and staff interview, it was determined that the facility failed to provide respiratory/oxygen services consistent with physician orders [REDACTED]. Findings include: The facility policy dated 4/06/20, entitled Oxygen Administration indicated that before instituting oxygen therapy the resident and orders for oxygen were to be verified. Resident R48's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Physician orders, dated 2/11/21, included an order for [REDACTED]. Observations of Resident R48 on 2/17/21, at 1:25 p.m. and on 2/18/21, at 9:15 a.m. revealed Resident R48 receiving oxygen at three liters via nasal cannula (a pronged device to deliver oxygen through the nostrils). During an interview on 2/19/21, at 9:04 a.m. the Nursing Home Administrator confirmed that Resident R48 was not receiving oxygen at the physician ordered rate and that there was no evidence of a titration (adjustment of a dose based on resident response) order for adjusting the oxygen delivery rate. 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on observations, review of Pennsylvania Department of Health, Health Alert Network (PA-HAN) 496 and staff interviews, it was determined that the facility failed to maintain measures to help prevent the potential for cross contamination related to changing personal protective equipment (PPE) on one of two units (Unit D). The Pennsylvania Department of Health, PA-HAN-496 entitled, Cohorting of Residents in Skilled Nursing Facilities, identified that For all units that house residents who are cases or exposed: Dedicate staff to these units. If shared staff working between wings/units is unavoidable, staff should be sure to change all PPE and perform hand hygiene when moving between affected and unaffected units. This should be limited to key staff that must cover more than one area. Observations of the facility on 11/30/2020, revealed COVID-19 positive residents with signage on their doors identified as a Red Zone ( area where residents diagnosed as COVID positive) room. There were other rooms in Unit D that were considered exposed but not confirmed COVID-19 positive. Staff were observed wearing PPE to include gowns, gloves, N-95 respirator masks, and a face shield. During an interview on 11/30/2020, at 1:15 p.m. Registered Nurse Employee E1, stated that employees are not required to change their gowns after exiting a COVID-19 positive resident room and before entering a COVID-19 negative resident room, unless the gown is visibly soiled. Observation on 11/30/2020, at 1:20 p.m. revealed Nurse Aide Employee E2 continuing to wear the same gown, face shield, N-95 mask through resident care areas and did not change PPE. During an interview on 11/30/2020, at 1:45 p.m. the Nursing Home Administrator confirmed staff do not change their gowns between COVID-19 positive and COVID-19 negative resident rooms routinely and only if they become visibly soiled after care. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of the Minimum Data Set (MDS-federally mandated standardized assessment conducted at specific intervals to plan resident care) User's Manual, clinical records, and staff interview, it was determined that the facility failed to ensure that the MDS assessments accurately reflected the status for one of 23 residents reviewed (Resident R2). Findings include: MDS User Manual Section N0410 [NAME] Medications Received indicates to code as the number of days the resident receives an anticoagulant in the last seven days or since admission/entry or re-entry, if less than seven days and to enter 0 if the medication was not received by the resident during the last seven days. Resident R2's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R2's Medication Administration Records for (MONTH) (YEAR) and (MONTH) 2019 revealed documentation that Eliquis (anticoagulant or blood thinner) five milligrams twice a day was administered during the entire seven day look-back periods from 12/20/18 to 12/26/18 and 6/20/19 to 6/26/19. Resident R2's MDS's with Assessment Reference Dates of 12/26/18 and 6/26/19, did not identify that Resident R2 received an anticoagulant and were coded 0 for anticoagulant use. During an interview on 7/11/19, at 9:50 a.m. Registered Nurse Assessment Coordinator Employee E2 confirmed that the 12/26/18, and 6/26/19, MDS's were not coded correctly to reflect Resident R2's anticoagulant usage. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Clinical Records

Based on review of facility policy and clinical records and staff interviews it was determined that the facility failed to maintain complete and accurate documentation for one of 23 residents (Resident R8). Findings include: The facility policy entitled Weight Protocol, dated 6/12/19, indicated that a significant weight change is considered if the resident has gained or lost 5% of body weight within one month; it must be investigated, the charge nurse must validate the weight change AND that proper technique was utilized to obtain that weight, and that a re-weigh is to be scheduled on the following day. Facility policy entitled Significant Weight Loss / Gain, dated 6/12/19, indicated that dietary would provide nursing with a list of residents with significant weight loss or gain (5% in 30 days and 10% in 180 days) during the third week of each month. Resident R8's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The clinical record further revealed a monthly weight on 4/19/19, of 92.6 pounds and a weight on 5/10/19, three weeks later, of 149 pounds, a potential 56.4 pound gain. Resident R8's clinical record lacked documentation by the physician, registered dietitian, or nursing staff related to the weight gain, possible causes, re-weigh, or recommendations for further monitoring or interventions. During an interview on 7/11/19, at 10:38 a.m. Registered Dietitian Employee E4 confirmed that Resident R8's clinical record reflected a 56.4 pound gain in three weeks and lacked evidence of dietary or nursing staff knowledge of the weight gain, possible cause, or the request for and completion of a reweigh to verify the accuracy of that weight. 28 Pa. Code 211.5(f) Clinical records

Based on clinical record review and staff interview, it was determined that facility failed to administer the correct medication to one of seven residents reviewed (Resident R1). Findings include: Resident R1's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R1's clinical record revealed a physician's orders [REDACTED]. Resident R1's (MONTH) (YEAR) Medication Administration Record [REDACTED]. There were no ill effects to either resident. During interview on 3/4/18, at 11:30 a.m. the Nursing Home Administrator confirmed that the wrong medication was administered to Resident R1 for a period of five days. 28 Pa. Code 211.12(c)(1)(2)(5) Nursing services Previously cited 6/23/17

Based on review of clinical records and the Resident Assessment Instrument (RAI) User's Manual (provides direction for the completion of the Minimum Data Set (MDS - periodic assessment of resident care needs)) and staff interviews, it was determined that the facility failed to consistently document the required supporting date and location of clinical information related to the Care Area Assessment (CAA - potential areas of resident problems) for eight of 16 residents (Residents R1, R2, R4, R5, R6, R7, R8 and R9). Findings include: The RAI User's Manual provides the instruction that the documentation related to the Care Area Assessments (CAAs) should indicate the basis for the care plan decision, why the finding requires an intervention, and the rationale for selecting specific interventions. For each triggered care area, the facility must indicate the date and location of where the information related to the CAAs can be found in the resident's clinical record. Review of Resident R1's Significant Change MDS assessment dated [DATE], revealed that the CAA summary did not consistently indicate the date or location of where supporting information related to the CAA could be found. Review of Resident R2's Significant Change MDS assessment dated [DATE], revealed that the CAA summary did not consistently indicate the date or location of where supporting information related to the CAA could be found. Review of Resident R4's Annual MDS assessment dated [DATE], revealed that the CAA summary did not consistently indicate the date or location of where the supporting information related to the CAA could be found. Review of Resident R5's Annual MDS assessment dated [DATE], revealed that the CAA summary did not consistently indicate the date or location of where the supporting information related to the CAA could be found. Review of Resident R6's Annual MDS assessment dated [DATE], revealed that the CAA summary did not consistently indicate the date or location of where the supporting information related to the CAA could be found. Review of Resident R7's Annual MDS assessment dated [DATE], revealed that the CAA summary did not consistently indicate the date or location of where the supporting information related to the CAA could be found. Review of Resident R8's Admission MDS assessment dated [DATE], revealed that the CAA summary did not consistently indicate the date or location of where the supporting information related to the CAA could be found. Review of Resident R9's Admission MDS assessment dated [DATE], revealed that the CAA summary did not consistently indicate the date or location of where the supporting information related to the CAA could be found. During a interview on 6/21/17, at 2:45 p.m., Registered Nurse Assessment Coordinator Employee E2 confirmed that the areas of concern triggered on the MDS CAA sheet did not consistently include the date and location of the information. 28 Pa Code 211.5(f) Clinical records Previously cited 4/19/17 28 Pa Code 211.12(d)(5) Nursing Services Previously cited 4/19/17, 5/04/16