Every finding on record at Lecom at Elmwood Gardens, LLC

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that a physician completed the initial comprehensive visit for one of ten new admissions reviewed (Resident R17).Findings include: A facility policy entitled Physician Services dated 11/26/25, indicated that physician visits, frequency of visits, emergency care of residents, etc. are provided in accordance with current regulations. Resident R17's clinical record revealed an admission date of 9/14/25, with diagnoses that included Diabetes (a health condition caused by the body's inability to produce enough insulin), Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), and high blood pressure. Resident R17's clinical record progress notes revealed he/she was seen by the Certified Registered Nurse Practitioner on 9/15/25, 10/6/25,11/4/25, and 12/30/25. The clinical record lacked evidence that he/she was seen by the physician. During an interview on 2/13/26, at 9:45 a.m. the Nursing Home Administrator confirmed that Resident R17 was not seen by the physician for the initial comprehensive assessment as required. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(f)(ii)(vii) Medical records

Based on review of facility policies, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in two of two resident refrigerators ([NAME] Unit and [NAME] Lane); failed to label food brought into the facility with the resident's name and use by date; and failed to maintain sanitary conditions in one of two resident refrigerators ([NAME] Unit). Findings include: Review of facility policy entitled, Food Brought by Family/Visitors, dated [DATE], revealed that perishable foods are to be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date and that nursing staff will discard perishable food on or before the use by date. Review of facility policy entitled, Food Receiving and Storage, dated [DATE], revealed that food services, or other designated staff, maintain clean and temperature/humidity-appropriate food storage areas at all times. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). Review of facility policy entitled Foods and Snacks kept on Nursing Units, dated [DATE], revealed that all foods belonging to residents are labeled with the resident's name, the item and the use by date. Observations on [DATE], at 2:48 p.m. revealed a refrigerator on [NAME] Unit used for residents contained a sandwich in a sealed container with a resident name but no use by date; a sandwich in a sealed container with a resident name and use by date of [DATE]; and six sealed Activia yogurts labeled with a resident name and expiration date of [DATE]. Inside the refrigerator, the bottom door shelf contained a pink/sticky liquid substance. The freezer contained a blue/sticky substance coating the bottom of the base of the freezer under the freezer drawer and multiple old, discolored ice cubes. During an interview on [DATE], at 2:55 p.m. Licensed Practical Nurse (LPN) Employee E2 confirmed that the refrigerator contained a sandwich lacking a use by date, a sandwich that was past the use by date, and six Activia yogurts that expired on [DATE], and stated they should be discarded. LPN Employee E2 also confirmed the refrigerator contained a pink sticky liquid substance and the freezer contained blue sticky substance and old discolored ice cubes and needed cleaned. Observations on [DATE], at 9:45 a.m. revealed a refrigerator on [NAME] Unit used for residents that contained five sealed cottage cheese cups with a use by date of [DATE]. During an interview on [DATE], at 9:48 a.m. LPN Employee E1 confirmed that the five sealed cottage cheese cups were expired and should be discarded. Observation on [DATE], at 10:11 a.m. revealed a refrigerator on [NAME] Lane used for residents that contained a sealed plastic container with blueberry cobbler with a resident's name on it and a use by date of [DATE], and also contained an eleven ounce bottle of Ensure nutritional drink with an expiration date of ,d+[DATE]. During an interview on [DATE], at 9:48 a.m. Registered Nurse Employee E3 confirmed that the resident who the blueberry cobbler was for, discharged from the facility and also that it was past the use by date, the Ensure drink was expired, and both should have been discarded. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(2.1) Management

Based on review of facility policy and infection control records, and staff interviews, it was determined that the facility failed to ensure measures were in place to monitor and prevent legionella in the facility water. Findings include: A facility policy, Infection Prevention and Control Plan FY2024, dated 11/14/24, revealed the infection control plan describes the process for the detection, prevention, and control of healthcare-associated infections (HAI), and disease transmission among residents, visitors, and healthcare personnel (HCP) (i.e., staff, providers, contractors/vendors, volunteers, and students). Water is tested at least quarterly for waterborne pathogens including Legionella. Response to positive test results is prescribed in the WMP (Water Management Plan). Facility policy, Legionella Water Management Program, dated 11/14/24, revealed the facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. Policy Interpretation and Implementation further indicated the facility will have a system to monitor limits and the effectiveness of control measures, a plan for when control limits are not met and/or control measures are not effective, and documentation of the program. Review of facility water management records, Special Pathogens Laboratory - The Legionella Experts dated 10/10/24, revealed positive results for Legionella rubrilucens in [NAME] Lane room [ROOM NUMBER], and positive results for L. pneumophila, not serogroups in the Skilled Hall Med Room. The facility lacked evidence of further testing for Legionella of the facility water system after 10/10/24. An interview with the Maintenance/Environmental Services Director on 2/13/25, at 9:25 a.m. revealed the facility received the positive findings for Legionella in the above noted areas on 10/10/24; Flushing of the facility water system with 160-degree water was completed, but no further testing of the water system for Legionella was completed after 10/10/24. He/she further confirmed that testing for Legionella should have been completed after the 10/10/24, positive results of Legionella, to ensure the usage of facility water was safe for all persons. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure that physician visits were conducted at least every 30 days for the first 90 days after admission for one of eight new admissions reviewed (Resident R42). Findings include: A facility policy entitled Physician Services dated 11/14/24, indicated that physician visits, frequency of visits, emergency care of residents, etc. are provided in accordance with current regulations. Resident R42's clinical record revealed an admitted [DATE], with diagnoses that included diabetes, high blood pressure, and congestive heart failure. Resident R42's clinical record progress notes revealed he/she was seen by the Certified Registered Nurse Practitioner on 11/18/24, and 12/16/24. The clinical record lacked evidence that he/she was seen in January 2025 as required by the physician. During an interview on 2/13/25, at 9:24 a.m. the Director of Nursing confirmed that Resident R42 was not seen by the physician as required in January 2025. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(f)(ii)(vii) Medical records

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure that the physician signed and dated all orders during each of his/her visits for four of 12 residents reviewed (Residents R26, R36, R37, and R42). Findings include: A facility policy entitled Physician Services dated 11/14/24, indicated that physician orders and progress notes are maintained with current regulations. Resident R26's clinical record revealed an admitted [DATE], with diagnoses that included diabetes (a health condition caused by the body's inability to produce enough insulin), high blood pressure, and endocarditis (inflammation of the inner lining of the heart chambers and valves usually caused by bacterial infection). Resident R26's physician's orders revealed that 7/02/24, at 9:59 a.m. was the last time his/her physician reviewed, signed, and dated his/her physician's orders. Resident R36's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, stroke resulting in paralysis of left side, and hypothyroidism (a condition resulting from decreased production of thyroid hormones). Resident R36's physician's orders revealed that 7/02/24, at 9:59 a.m. was the last time his/her physician reviewed, signed, and dated his/her physician's orders. Resident R37's clinical record revealed an admitted [DATE], with diagnoses that included congestive heart failure (CHF-progressive heart disease that affects the pumping action of the heart resulting in difficulty breathing and tiredness), and multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), and neurogenic bladder (when the nerves or the brain cannot communicate effectively to the muscles in the bladder). Resident R37's physician's orders revealed that 7/02/24, at 9:59 a.m. was the last time his/her physician reviewed, signed, and dated his/her physician's orders. Resident R42's clinical record revealed an admitted [DATE], with diagnoses that included diabetes, high blood pressure, and CHF. Resident R42's physician's orders revealed that his/her physician orders had not been reviewed, signed, and dated by his/her physician. During an interview on 2/12/25, at 11:02 a.m. Registered Nurse Assessment Coordinator confirmed that the physician orders for Residents R26, R36, R37, and R42 were past due for being reviewed and signed by the physician During an interview on 2/13/25, at 8:50 a.m. the Director of Nursing (DON) confirmed that physician orders for Residents R26, R36, and R37 should have been signed every sixty days and were not signed in September 2024, November 2024, or January 2025 as required. The DON also confirmed that Resident R42's physician orders should have been signed in November 2024 at the time of admission and every thirty days thereafter for the first ninety days, which included December 2024 and January 2025. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(f)(i) Medical records

Based on review of facility policy and clinical records, and staff interview it was determined that the facility failed to develop a comprehensive care plan for one of 13 residents reviewed (Resident R27). Findings include: A facility policy dated 3/20/24, entitled Care Plans indicated that the facility will develop a comprehensive care plan for each resident that includes measurable objectives, and timetables to meet residents medical, nursing, and mental / psychosocial needs of the resident. Resident R27's clinical record revealed an admitted [DATE], with diagnoses that included diabetes, transient ischemic attack (TIA - minor stroke or mini-stroke with noticeable symptoms going away) and obstructive sleep apnea (a disorder that makes you stop breathing repeatedly during sleep). Resident R27's clinical record revealed a physician's order 1/15/24, for Seroquel (psychotropic medication - affects the mind) 25 milligram (mg) by mouth at bedtime for depression and anxiety. Another physician's order dated 3/6/24, indicated the Seroquel dosage was increased to 50 mg at bedtime for delusions. The clinical record lacked evidence that a care plan had been developed to address Resident R27's behaviors and use of Seroquel. During an interview on 3/28/24, at 11:14 a.m. confirmed that a care plan had not been developed to address Resident R27's behaviors and use of Seroquel. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on 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 a PRN (as needed) psychotropic (affecting the mind) medication for one of five residents reviewed for unnecessary medications (Resident R158). Findings include: A facility policy dated 3/20/24, entitled Unnecessary Drugs indicated that non-pharmacological interventions are considered and used when indicated. Review of Resident R158's clinical record revealed an admitted [DATE], with diagnoses that included anxiety, depression, and gastro-esophageal reflux disease (a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]). Review of Resident R158's clinical record revealed a physician's order dated 3/19/24, that identified to administer Clonazepam (medication to treat anxiety) 1 milligram (mg) by mouth every 8 hours as needed for anxiety until 4/2/24. Review of Resident R158's Medication Administration Record (MAR) for March 2024 revealed that the PRN Clonazepam was used 18 times between 3/19/24, and 3/28/24. Review of the March 2024 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions were attempted prior to the administration of the PRN Clonazepam 18 of the 18 times the Clonazepam was utilized in March 2024. During an interview on 3/28/24, at approximately 2:22 p.m. the Director of Nursing confirmed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Clonazepam 18 of the 18 times it was administered to Resident R158 between 3/19/24, and 3/28/24. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 201.18(b)(1)(3) Management

Based on review of clinical records and facility documentation and staff and resident interviews, it was determined that the facility failed to identify the development of a pressure ulcer for one of four residents (Resident R1) reviewed resulting in the formation of an unstageable pressure injury. This deficiency is cited as past non-compliance. Findings include: Protocol for skin assessment in an interview with the Director of Nursing (DON) on 2/17/22, at 3:32 p.m. revealed that the Nurse Aides (NA) are to observe resident's skin while in the shower/bath/bed bath and if any skin issues are observed by the NA, the nurse is to be notified. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of NA bathing documentation for 1/25/22, 1/29/22 and 2/01/22, indicated Resident R1 had other as bathing and there was no documentation of any abnormal skin issues. Review of Resident R1's Potential for Skin Breakdown care plan initiated on 11/15/21, revealed a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's clinical record revealed a nursing note dated 2/03/22, at 9:15 p.m., revealed that Resident R1 returned from a podiatry (foot doctor) appointment and the podiatrist identified that Resident R1 had a new pressure ulcer to the right heel. The wound was measured on return, measuring 4.1 centimeters (cm) by 3.5 cm and treatment initiated. Review of the podiatrists notes, completed on 2/03/22, stated in regards to the patient's right heel ulceration, it is not clear at the time of the dictation if the facility is aware of this. Resident R1 was ordered a prafo (device worn on the calf and foot to help prevent pressure ulcers) boot, x-rays and a vascular surgeon consult. Under the physical exam portion of the podiatry notes, it stated right heel ulceration is noted with mixture of black dry eschar [dead skin tissue] as well as partial thickness red granular base.No deep tissue is palpable today but breakdown is unstageable under eschar. Visit diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's January 2022 Treatment Record revealed Cavalon was applied to the bilateral heels on 1/28/22 and 1/31/22. Facility documentation, dated 2/04/22, revealed that Licensed Practical Nurse (LPN) Employee E1 had signed the treatment record that Cavalon was applied to Resident R1's heel on those days. LPN Employee E1 statement identified that they did not disturb residents if they are resting, does not turn a light on and just reaches under lifted foot and applies medication without looking. Education provided to LPN Employee E1 identified that all residents with Cavalon to heels should have heels visualized when applying to ensure that the intervention is successfully protecting, and was signed by the DON. During an interview on 2/16/22, at 2:37 p.m. Resident R1 stated that he had to wear this boot (prafo boot) and that his right heel was sore. Since the resident had a left lower leg amputation, it was hard to get around per Resident R1. During an interview on 2/17/22, at 1:53 p.m. the DON confirmed that the facility was unaware of Resident R1's unstageable right heel wound until Resident R1 was seen by the podiatrist. This deficiency is cited as past non-compliance. On 2/04/22, the facility initiated a plan of correction to address the failure to identify a new unstageable pressure ulcer to Resident R1's heel that included the following: Education to LPN Employee E1 on 2/04/22 Orders were obtained to treat Resident R1's unstageable pressure area All residents were observed for any new skin issues to ensure that there were no other missed wounds by 2/07/22 Any new wounds identified to have treatment plans completed, educated clinical staff on a change in the process of skin checks with education communicated by 2/04/22 and protocol written and distributed. On the first shower day of the week, the nurse aide will coordinate with the LPN to complete a full body skin check at the time of a residents shower/bath. Those that receive bed baths will be inspected on Wednesday. If any areas are identified, then an incident report is completed. All staff were educated on the Stop and Watch forms (facility communication form to assist in identifying resident change in condition). Audits were initiated daily on 2/04/22 for any new wounds, skin checks reviewed on Wednesday by the Director of Nursing. Competencies were initiated on 2/17/22 to assure staff are following new protocol. Interview conducted on 2/17/22, at 11:02 a.m. with LPN Employee E2 and NA Employee E3 at 11:12 a.m., who each confirmed that they had received the education on the new skin assessment process and stated the process appropriately. Documentation provided by the facility during an interview on 2/16/22, at 11:10 a.m. with the DON confirmed that the facility had achieved compliance with identifying new skin issues at this time and will continue to monitor and review through the Quality Assurance Committee. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, observation, and staff interview, it was determined that the facility failed to prevent the potential for cross contamination (the spreading of germs/microorganisms from one surface to another) during a dressing change for one of one residents reviewed (Resident R25). Findings include: Review of the facility policy entitled Skilled Nursing-Dressing Change Policy, dated 6/23/21, revealed that after removing a soiled dressing, the nurse is to remove gloves, pulling inside out over dressing. Discard into appropriate receptacle. Wash hands and put on clean gloves. Resident R25's clinical record revealed an admitted [DATE], with a current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician's orders dated 6/04/21, revealed that the wound should be cleaned with wound cleaner, pat dry, apply Dakins 0.125% solution (debriding liquid) soaked gauze, cover with ABD pad dressing (thick padded dressing) and secure with tape, every day and as needed. Observation on 7/19/21, at 1:30 p.m. of Resident R25's wound care to buttocks region, revealed that Registered Nurse (RN) Hospice Employee E1, removed the soiled dressing, and did not remove dirty gloves and wash hands before cleaning the wound and applying the new clean dressing. During an interview on 7/19/21 at 1:45 p.m., RN Hospice Employee E1 confirmed that he/she did not remove dirty gloves and wash hands after removing soiled dressing prior to applying the new clean dressing. During an interview on 7/19/21, at 3:30 p.m. the Director of Nursing confirmed that staff are to wash hands and apply clean gloves after removing a soiled dressing. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to maintain accurate and complete documentation for one of 15 residents (Resident R7). Findings include: Resident R7's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Resident R7's current signed physician orders, dated 10/02/19, included orders for ace wraps to be applied to the lower legs in the morning and removed at night; [MEDICATION NAME] Barrier Wipes (provides a protective film on the skin preventing skin breakdown) to be applied to the bilateral lower heels/feet every third day; and an order for [REDACTED]. Observations on 10/07/19, at 2:55 p.m. and on 10/08/19, at 1:30 p.m. revealed Resident R7 out of bed in a reclining chair and in a wheelchair, respectively, with swollen legs covered in elastic wraps and no Z-flex boot on the right foot. During an interview at the time of the second observation, Resident R7 indicated that the Z-flex boot was in the cupboard and that I haven't worn it in ages . there's even a picture of how it's to be worn on the cupboard door . sometimes I admit I won't wear it. Observations of the interior cupboard revealed an undated picture of the boot to be applied to the right foot. Further review of Resident R7's clinical record, revealed no evidence in the treatment record or in the interdisciplinary progress notes of the boot's use since being ordered in (MONTH) 2019. During an interview on 10/10/19, at 8:47 a.m. Licensed Practical Nurse (LPN) Employee E2 indicated that Resident R7 has a history of redness and intermittent skin breakdown to both heels, that the Z-flex boot was originally to be applied to a the left foot, not the right foot as indicated in the order, due to blistering to the left heel identified in (MONTH) 2019. LPN Employee E2 further indicated the left heel had since healed (8/07/19), and that the boot was then to be discontinued. During an interview on 10/10/19, at 10:30 a.m., the Director of Nursing confirmed that Resident R7's clinical record did not accurately reflect the care and services to Resident R7's heels and that there was no evidence of the boot's use in the treatment record or other areas of the clinical record. 28 Pa. Code 211.5(f)(g)(h) Clinical records 28 Pa. Code 211.12(d)(1)(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 interviews it was determined that the facility failed to ensure that the MDS assessments accurately reflected the status for one of 15 residents reviewed (Resident R9). Findings include: Resident R9's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The MDS user manual guidelines indicates that an indwelling catheter (including suprapubic catheter and nephrostomy tube) is to be checked if it has been used at any time in the past 7-days. The MDS user manual guidelines also indicates that urinary continence is to be coded as not rated if during the seven-day look-back period the resident had an indwelling bladder catheter, condom catheter, ostomy, or no urinary output for the entire seven days. Resident R9's physician orders [REDACTED]. Resident R9's MDS with an Assessment Reference Date (ARD) of 3/4/19, was coded as None of the above for Bladder Appliances, although Resident R9 had an indwelling catheter in place. Resident R9's MDS's with an ARD of 6/11/19, and 7/23/19, were coded as always continent for urinary continence, although Resident R9 had an indwelling catheter for the entire seven-day look-back period. During an interview on 10/9/19, at 11:02 a.m. Registered Nurse Assessment Coordinator confirmed that the 3/4/19, MDS was coded incorrectly regarding the presence of a bladder appliance and the 6/11/19 and 7/23/19, MDS's were coded incorrectly regarding urinary continence. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Clinical Records

Based on review of clinical records and facility policy and staff interview, it was determined that the facility failed to update a care plan with a change in condition for one of 15 residents (Resident R20). Findings include: The 10/23/18, facility policy entitled Skilled Nursing Comprehensive Care Plans, indicated that assessments of residents are ongoing and that care plans are revised as information about the resident and their condition changes. Resident R20's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. The clinical record further indicated that Resident R20 developed a cough and congestion and on 9/30/19, had a chest x-ray indicating the development of an early pneumonia. Resident R20's physician ordered [MEDICATION NAME] (an antibiotic) 250 milligrams to be given twice a day, for ten days. Resident R20's current care plans revealed no evidence that the care plan was updated to address the new respiratory infection and associated treatment. During an interview on 10/09/19, at 12:35 p.m. the facility Registered Nurse Assessment Coordinator indicated the care plan was not updated to reflect Resident R20's change in condition and care until brought to the facility's attention on 10/09/19. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and staff interview, it was determined that the facility failed to provide the resident and/or resident representative with a notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon transfer out of the facility for three of 15 residents reviewed (Residents R15, R22 and R47). Findings include: Resident R15's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. An interdisciplinary note dated 7/28/19, indicated that Resident R15 was transferred to the hospital after becoming unresponsive. There was no evidence that the resident and/or resident representative was provided the notice of bed hold policy. Resident R22's clinical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. An interdisciplinary note dated 7/02/19, indicated that Resident R22 was transferred to the hospital after becoming unresponsive in the dining room. There was no evidence that the resident and/or resident representative was provided the notice of bed hold policy. Resident R47's clinical record indicated that Resident R47 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An interdisciplinary note dated 9/08/19, indicated that Resident R47 was transferred to the hospital after developing purulent (pus-like) drainage from around the [MEDICAL CONDITION]. There was no evidence that the resident and/or resident representative was provided the notice of bed hold policy. During an interview on 10/09/19, at 10:30 a.m. the Director of Nursing confirmed that Residents R15, R22, and R47's clinical records lacked evidence that the bed hold policy was provided. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(f) Resident rights

Based on observations, review of facility policy and staff interview, it was determined that the facility failed to dispose of expired medications in one of two medication rooms (100 Hallway). Findings include: The facility policy entitled Medication Storage in the Facility dated 10/23/18, indicated that outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal and reordered from pharmacy. Observation on 10/08/19, at 10:15 a.m. revealed 100 Hallway's medication room to have 31 (two stored in the medication refrigerator and 29 in the cupboard) [MEDICATION NAME] (laxative), 10 milligram suppositories labeled with expiration dates of (MONTH) 2019. During an interview at the time of the observation, Licensed Practical Nurse Employee E1 confirmed that the suppositories were expired and should be removed from inventory in the medication room. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, review of facility policies, and staff interviews, it was determined that the facility failed to maintain appropriate infection control measures when transporting soiled laundry into the laundry room for three of three wings (West, 100, and 110 Wings) and to prevent the spread of infection while administering medications for one of seven residents observed during medication administration (Resident R16). Findings include: The Infection Control - Laundry policy dated 9/29/16, revealed that there should be a separate area for washing soiled laundry and storing clean laundry. An observation of the laundry room on 10/6/17, at 9:30 a.m., revealed that the soiled laundry was brought into the laundry room, past the storage area for clean clothes, and then put into the washer. The cart covers used for storage of clean clothes were not tightly closed and the fan was causing the cart covers to flap open, further exposing the clean clothes to environmental conditions. During an interview on 10/6/17, at 10:38 a.m., Maintenance/Environmental Services Director Employee E1 confirmed that the cart covers should have been tightly closed. The Oral Medication Administration policy, dated 9/29/16, revealed that pour or push the correct number of tablets or capsules into the souffle (paper or plastic) cup, taking care to avoid touching the tablet or capsule, unless wearing gloves. During observation of medication administration on 10/04/17, between 3:50 p.m. and 4:45 p.m., the following was observed: Licensed Practical Nurse (LPN) Employee E2 attempted to place three of Resident R16's medications into a cup and two of the medications dropped onto the medication cart. LPN Employee E2 picked the medications up with their bare hands and placed the medications into a cup with the other medication. The pills were crushed and administered to Resident R16. During an interview on 10/04/17, at 4:40 p.m., LPN Employee E2 confirmed that gloves should have been worn when picking the medications up off the medication cart. 42 CFR 483.65 Infection Control, Prevent Spread, Linens Previously cited 11/04/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 11/04/16 28 Pa. Code 205.26(c) Laundry 28 Pa Code 211.12(d)(1)(3)(5) Nursing services Previously cited 11/04/16

Based on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to update a resident centered care plan for one of 12 residents (Resident R4). Findings include: The Comprehensive Care Plans policy, dated 9/29/16, revealed that care plans need to be revised when residents' information or condition change. Resident R4's clinical record showed an admitted [DATE], with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. physician's orders [REDACTED]. Resident R4's current care plan dated 8/28/17, revealed under the section activity of daily living and falls, a maxi lift with assist of two was to be used and under sections for skin breakdown, bowel and bladder, and bed mobility/transfer, a slide transfer board with assist of two was needed. During an interview on 10/5/17, at 4:15 p.m., Director of Nursing confirmed that Resident R4's care plan had not been updated. 28 Pa. Code 211.5(f) Clinical records Previously cited 11/4/16 28 Pa. Code 211.12(d)(1)(3)(5)Nursing services Previously cited 11/4/16

Based on review of a closed clinical record and staff interview, it was determined that the facility failed to complete a discharge summary that included a recapitulation of a resident's stay for one of one discharged residents (Resident CR12). Findings include: The closed clinical record revealed that Resident CR12 was admitted to the facility on [DATE] and discharged home on[DATE]. There was no documentation completed on a discharge summary that included a recapitulation of Resident CR 12's stay in the facility. During an interview on 10/6/17, at 11:30 a.m., Medical Records Employee E4 confirmed that a discharge summary including a recapitulation of resident's stay was not completed for Resident CR12. 28 Pa. Code 211.5(f) Clinical records Previously cited 11/4/16

Based on observations, review of facility policies and staff and pharmacy interviews, it was determined that the facility failed to demonstrate the accurate administration of a gel medication for one of 16 residents (Resident R3) and provide the current dose of a medication when ordered for one of 16 residents (Resident R9). Findings include: Resident R3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. During observation of medication administration on 10/04/17, at 4:40 p.m., Licensed Practical Nurse (LPN) Employee E2 retrieved the gel medication for pain, placed gloves on and squeezed out an amount on the gloved hand. The medication was rubbed into Resident R3's right shoulder. After returning to the medication cart, when asked how the LPN knew that two grams were administered, LPN Employee E2 replied I'm not sure how much two grams is. During a phone conversation on 10/05/17, at 12:10 p.m., with the pharmacist, it was explained that the medication [MEDICATION NAME] gel was sent with a measurement tool in the clear plastic bag to show how much gel to apply. During an interview on 10/05/17, at 12:20 p.m., LPN Employee E3 revealed that there is a reusable plastic measuring instrument sent with the medication and was available for use and was not used. Resident R9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The October 2017 Medication Administration Record, [REDACTED]. During an interview on 10/06/17, at 10:03 a.m. the Director of Nursing confirmed that Resident R9 did not receive the 9/27/17, physician ordered dose of [MEDICATION NAME]. 483.25 Previously cited state deficiency 11/04/16 28 Pa Code 211.12(d)(1)(3)(5) Nursing services Previously cited 11/04/16

Based on record review, review of the Resident Assessment Instrument (RAI) User's Manual and staff interview, it was determined that the facility failed to document required information regarding the assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS-periodic assessment of care needs) for five of 11 residents (Residents R3, R4, R5, R6 and R7). Findings include: The RAI User's Manual provides the instruction that the documentation related to the Care Area Assessments (CAAs) should include the basis for the care plan decision, why the finding requires an intervention and the rationale for selecting a specific intervention. For each triggered area, the facility must indicate the date and location where the information related to the CAAs can be found in the resident's clinical record. Review of Resident R3's significant change MDS assessment, dated 6/20/16, revealed that the CAA summary did not consistently indicate the location and date of where the information related to the CAA could be found. Review of Resident R4's admission MDS assessment, dated 6/03/16, revealed that the CAA summary did not consistently indicate the location and date of where the information related to the CAA could be found. During an interview on 11/03/16, at 2:20 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E4 confirmed that the CAA Summary for the MDS assessments for Residents R3 and R4 lacked the location and the dates where the information related to the CAAs could be found in the clinical record. Review of Resident R5's significant change MDS assessment, dated 8/16/16, revealed that the CAA summary did not consistently indicate the location and date of where the information related to the CAA could be found. Review of Resident R6's annual MDS assessment, dated 3/22/16, revealed that the CAA summary did not consistently indicate the location and date of where the information related to the CAA could be found. Review of Resident R7's significant change MDS assessment, dated 10/05/16, revealed that the CAA summary did not consistently indicate the location and date of where the information related to the CAA could be found. During an interview on 11/03/16, at 9:55 a.m. a.m. the RNAC confirmed that the CAA Summary for the MDS assessments for Residents R5, R6, and R7 as noted above, lacked the location and the dates where the information related to the CAAs could be found in the clinical record. 28 Pa Code 211.5(f) Clinical records 28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 10/02/15

Based on review of clinical records and facility policy and staff interviews it was determined that the facility failed to notify the physician and/or family or responsible party of a change in condition for three of 18 residents (Residents R1, R2 and R14). Findings include: The facility Notification of Physician and Family policy dated 9/29/16, stated that It is the policy of Presbyterian Homes to notify the resident, attending physician and resident responsible party of changes in the resident's condition or status and that nursing will notify the resident, the responsible party and the attending physician when there is a need to alter a resident's treatment significantly. Nurse's notes dated 9/29/15, at 3:15 p.m. stated that Resident R14 had an open area of the right great toe and second toe. The clinical record lacked evidence that the physician was notified of the open area on Resident R14's right great toe and second toe until 10/02/15, three days later. During an interview on 11/02/16, at 2:30 p.m. the Director of Nursing (DON) confirmed the delay in notifying the physician regarding Resident R14's ulcer. The Admission Record face sheet revealed that Resident R1 was admitted [DATE]. The 10/12/16 Quarterly Minimum Data Set Assessment (MDS-periodic assessment of resident care needs) indicated that Resident R1 had [DIAGNOSES REDACTED]. A 10/17/16 physician's orders [REDACTED]. The 6/01/16 through 10/01/16 Treatment Administration Record (TAR) revealed that Resident R1 did not receive the treatment as ordered by the physician on 20 occasions over a five month period. Resident R1's clinical record lacked documentation to indicate the physician was notified that Resident R1 was not receiving the treatment as ordered on 20 occasions over a five month period During an interview on 11/01/16, at 4:40 p.m., the Director of Nursing confirmed that there was no documented evidence to indicate that the facility notified the physician on the failure to provide a treatment on 20 occasions over a five month period. The Admission Record face sheet revealed that Resident R2 was admitted [DATE]. The 9/13/16 Quarterly MDS indicated that Resident R2 had [DIAGNOSES REDACTED]. Review of the Ulcer Report dated 9/21/16 revealed that Resident R2 had acquired a pressure ulcer. Review of the nurses notes lacked documentation that the family was notified of the 9/21/16 pressure ulcer as of 11/02/16. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 10/02/15