Every finding on record at Lgar Health And Rehabilitation

Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to identify and investigate an incident of possible abuse and/or neglect for three of five incidents reviewed (Resident R6, R25, and R49). Findings include: A review of the facility policy Abuse, Neglect, Exploitation, Misappropriation or Resident Property and Prohibition Prevention reviewed 7/29/24, indicated the facility will do everything within its control to prevent and prohibit resident abuse, neglect, exploitation, or misappropriation of resident property. Staff will identify and observed or suspected occurrence, pattern, or here say, and report it to a supervisor for prompt investigation. The facility will investigate all allegations or occurrences of abuse, neglect, exploitation or misappropriation of resident property and will determine where the results are to be reported, if necessary. A review of the facility policy Incident and Accident Reports reviewed 7/29/24, indicated to document both incidents and accidents involving residents for use as an internal tool to investigate the event and to help prevent future similar events. Provide for the initiation of an investigation when there is an injury of undetermined origin. Witness statements are to be obtained by all parties involved at the time of the incident or accident. A review of the clinical record indicated Resident R6 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's Disease (brain disorder that slowly destroys memory, thinking, and the ability to carry out the simplest tasks), depression, and reduced mobility. A review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 8/1/24, revealed the diagnoses remain current. Review of the care plan dated 9/2/22, indicated Resident R6 was at risk for falls and to ensure he was wearing appropriate footwear. Review of facility provided documents dated 5/9/24, revealed during a mechanical lift transfer, Resident R6's foot slipped off the lift and he received an abrasion to his left shin. There is no evidence the facility investigated the incident to confirm the lift was in working order, had any sharp points that could have injured the resident, if proper footwear was used, and failed to obtained witness statements regarding the incident. During an interview on 10/16/24, at 9:35 a.m. Licensed Practical Nurse (LPN) Employee E2 stated she completed the incident report for Resident R6 on 5/9/24. She stated she was not involved in the incident and was not Resident R6's nurse on 5/9/24. She stated she did not know how to fully fill out the facility's incident report. Review of the clinical record indicated Resident R25 was readmitted to the facility on [DATE], with diagnoses that included overactive bladder, depression, and diabetes. Review of the MDS dated [DATE], revealed the diagnoses remain current. Review of facility provided documents dated 9/24/24, indicated Resident R25 asked Nurse Aide (NA) Employee E 1 who was on her cell phone while providing care to Resident R25 and ignored her attempt get her attention, and when Resident R25 asked for her Kleenex box, NA Employee E1 threw the box towards Resident R25, turned and exited the resident's room. NA Employee E1 was terminated from the facility on 9/27/24, following this incident. The facility did not fully investigate the incident to ensure other residents were not affected and did not obtain witness statements from residents or staff on shift. Review of the clinical record indicated Resident R49 was readmitted to the facility on [DATE], with diagnoses that included dementia (group of symptoms affecting memory, thinking and social abilities), Parkinsonism (term used to describe collection of movement symptoms like stiffness, balance issues, and tremor), and depression. Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of facility provided documents dated 9/10/24, indicated it was reported to staff that NA Employee E1 was overheard speaking unkindly to Resident R49. Resident R49 was told I'm not taking that from you, put the pillow under your head. You have to stay in bed. The facility removed NA Employee E1 from that assignment, and she no longer provided care to Resident R49. The facility failed to fully investigate the incident to ensure other residents were not affected and did not obtain witness statements from residents or all staff on shift. During an interview on 10/17/24, at 9:00 a.m. the Director of Nursing confirmed the facility failed to identify and investigate an incident of possible abuse and/or neglect for Residents R6, R25, and R49. 28 Pa. Code: 201.14(a)(c)(e) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management.

Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to provide adequate supervision to prevent falls for one of five residents (Resident R16). Findings include: A review of the clinical record indicated Resident R16 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease with late onset (a progressive disease that destroys memory and other important mental functions), hyperlipidemia, abnormal posture, muscle weakness, and difficulty walking. A review of Resident R16's care plan initiated on 5/15/24, indicated for bed mobility: the Resident R16 requires extensive assistance by two staff to turn and reposition in bed and bilateral body pillows when in bed to assist with positioning. A review of Resident R16's quarterly Minimum Data Set (MDS- periodic assessment of resident care needs) dated 6/13/24, indicated that Resident R16 had a bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) of total dependence of staff with support of two plus persons. A written statement by Nurse Aide (NA) Employee E3 dated 9/3/24, states I was in the middle of changing resident in bed. She was rolled on her side. I was holding onto her putting brief under her. She started reaching over for something on the other side of the bed and rolled out of bed. A review of Resident R16's nurse practitioner note dated 9/5/24, indicated Resident R16 was seen for an acute fall that occurred on 9/3/24 at approximately 9:15 p.m. CNA E3 was providing care at bedside when Resident R16 rolled out of bed. During an interview on 10/17/24, at 2:23 p.m. the Director of Nursing confirmed the above findings and that the facility failed to provide adequate supervision for Resident R16. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services.

Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care to possibly prevent hospitalization for one of five residents (Resident R18). Findings include: Review of the facility policy, Change in Status/Resident Condition dated 7/17/23, indicated the facility will notify the physician and representative of changes in the resident ' s condition. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record revealed that Resident R18 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 9/21/23, included diagnoses of pyogenic arthritis (painful injection in a joint), Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), and anemia (too little iron in the body causing fatigue). Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R18's score to be 12. Review of the facility diagnosis list included gastro-esophageal reflux disease (GERD, when stomach acid repeatedly flows back into the tube connecting your mouth and stomach) present upon admission, with a beginning date of 6/17/19. Review of Resident R18's care plan for GERD initiated 5/25/23, included the intervention Monitor/document/ report as need signs and symptoms of GERD: Belching, coughing/choking when lying down, heartburn, dyspepsia, nausea/vomiting, indigestion, regurgitation, increased salivation, swallowing problems, bitter taste in mouth, dysphagia (difficulty swallowing), substernal chest pain, increased gag response. Review of multiple physician's orders for Zofran (Ondansetron, medication used to prevent nausea and vomiting) dated 5/17/23 (reordered 7/28/23, 8/30/23, and 9/15/23) indicated Resident R18 is to receive one 4mg tablet, every eight hours for nausea and vomiting, as needed. Review of Resident R18 Medication Administration Record (MAR) for June, July, and August 2023, through hospitalization on [DATE], revealed the following: June: Zofran administered two times (23, 28). July: Zofran administered three times (13, 15, 19). August: Zofran administered 16 times (2, 9, 11, 13, 14, 16, 18, 19, 20, 21, 22 twice, 23, 24 twice, and 25). Review of a progress note dated 8/9/23, at 9:39 a.m. indicated Medicated with Zofran this am per her request for nausea. Review of a progress note dated 8/19/23, at 4:52 a.m. indicated Was medicated with Tums and Zofran at 01:10 and 02:01 respectively related to epigastric discomfort and nausea. Review of a progress note dated 8/19/23, at 9:06 a.m. indicated Resident was vomiting when I came on duty this AM. Per 11-7 (11:00 p.m. - 7:00 a.m.) nurse she had been medicated for c/o (complaints of) n/v (nausea and vomiting). Review of a progress note dated 8/20/23, at 9:37 a.m. indicated Resident R18 Requested Zofran this AM (morning) for c/o nausea. Review of a progress note dated 8/21/23, at 9:34 a.m. indicated Resident R18 Requested Zofran for c/o nausea. Review of a progress note dated 8/22/23, at 1:00 p.m. indicated Resident R18 Requested Zofran for c/o nausea. Review of a progress note dated 8/22/23, at 9:29 p.m. indicated Resident R18 C/O nausea , medicated with Zofran. Review of a progress note dated 8/23/23, at 9:29 p.m. indicated Resident R18 C/O nausea , medicated with Zofran. Review of a progress note dated 8/24/23, at 9:39 p.m. indicated Resident R18 Requested Zofran for c/o nausea. Review of a progress note dated 8/25/23, at 6:24 a.m. indicated Answered call light Resident (R18) said she had vomited, I turned her bedside lamp on and noticed large. thick coffee ground emesis, denies pain or discomfort, was medicated earlier at 03:29 for c/o nausea Zofran given. Review of a progress note dated 8/25/23, at 7:19 a.m. indicated Resident R18 was transferred to the hospital. Review of a progress note dated 8/30/23, at 4:30 p.m. indicated Resident R18 returned to the facility from the hospital. Review of hospital paperwork dated 8/29/23, indicated Resident had been admitted to the hospital with an acute gastric ulcer with bleeding (a new onset stomach ulcer, with bleeding present). The presenting problems noted during the hospital stay were hematemesis (vomiting of blood), GI bleed (bleeding in the digestive tract), acute gastric ulcer with bleeding, and vomiting. Review of the clinical record failed to reveal a notification to the provider of the increased nausea and use of Zofran. During an interview on 10/26/23, at 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that residents were provided appropriate treatment and care to possibly prevent hospitalization for 1 of 4 residents. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to make certain that medications, biologicals and medical supplies were properly stored or disposed of in one of one medication rooms. Findings include: Review of the facility pharmacy policy Storage of Medications dated 3/16/23, indicated medications are stored properly, following manufacturer's or provider recommendations, to maintain their integrity and to support safe effective drug administration. Outdated, contaminated, discontinued, or deteriorated medication and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock. During an observation on the facility medication room on 10/25/23, at 1:17 p.m. the following was observed: -(4) One-liter bags of intravenous (IV) fluid, with the overwrap removed stored above the medication room sink -Under the sink, six bottles of drug disposal liquid, one lunch bag with food within it, a bottle of water, a bottle of nail polish remover, and four boxes of isolation masks. During an interview on 10/25/23, at 1:22 p.m. the Registered Nurse Employee E1 confirmed the above observation, and further confirmed that without the overwrap on the IV fluid, the injection port was accessible to inject a substance into the fluid. During an interview on 10/26/23, at 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain improperly stored medications, biologicals and medical supplies were properly stored or disposed of in one of one medication rooms. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.9 (a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

Based on review of facility policy, personnel records, and staff interview it was determined that the facility failed to complete annual performance evaluations for two out of five nurse aide personnel records (NA Employee E2 and E3). Findings include: Review of the facility provided staff listing indicated that Nurse Aide (NA) Employee E2 was hired on 10/18/07. Review of NA Employee E2's most recent performance review revealed it was completed on 11/9/21. Review of the facility provided staff listing indicated that NA Employee E3 was hired on 5/8/09. Review of NA Employee E3's most recent performance review revealed it was completed on 4/23/20. During an interview on 10/26/23, at 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to complete annual performance evaluations for two of five nurse aides as required. 28 Pa Code: 201.20 (a)(b)(c)(d) Staff development. 28 Pa Code: 201.14 (a) Responsibility of licensee.

Based on review of clinical records and facility investigation reports and staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards for residents who were at risk for falls two of four residents (Residents R3 and R4) when they were transferred with assistance of one staff not two as required and sustained a fall with no injuries. Findings include: During an interview on 8/15/23, at 8:35 a.m., with Nurse Aide (NA) Employee E1 and E2 indicated that transfer status of all residents is discussed with staff between shifts with report , it is on the kardex at the nurses station and updated as needed and also there are colored blocks of paper above each residents closet indicating transfer status, fluid consistency, and meal consistency. The staff also stated that if a new staff person comes in the staff always go over care of each resident prior to their start of shift. This was confirmed with the Registered Nurse (RN) Employee E3. Review of the clinical record indicated that Resident R3 was admitted to the facility on [DATE], with diagnoses which included abnormal posture, seizures, blindness, closed fracture of the right hip, and cognitive communication deficit. A MDS dated [DATE], indicated the diagnoses remained current. Review of Resident R3's plan of care revised on 3/15/23, indicated that Resident R3 required assistance of the sit to stand lift (lift used to assist residents with limited mobility from sitting to standing position) with two staff. Review of a Resident Family Concern Form dated 6/12/23, indicated that Resident R3 voiced a complaint regarding the daylight Nurse Aide from the previous date (6/11/23), was giving care without telling the resident what she was doing and pulled her arm and moved her about the bed roughly enough to cause her to call out that she was being hurt. Then the resident stated that the NA began to transfer her from the bed without the sit to stand and when she asked the NA about it, the NA stated that she does things two ways, a bear hug or the sit to stand. Then the NA bear hugged the resident and plopped her like a sack of potatoes into the wheelchair. after this the resident went on to state that the NA was not nice and when Resident R3's roommate yelled out when she heard how the NA was treating Resident R3, the NA told the roommate to mind her own business and that it didn't concern her and closed the privacy curtain angrily. The NA refused to tell Resident R3 her name. Resident R3 stated that she wasn't used to being treated that way and was a little sore. from the rough treatment. The staff NA was identified as NA Employee E5. Review of the clinical record indicated that Resident R4 was admitted to the facility on [DATE], with diagnoses which included Stroke, falls, bladder disorder and difficulty walking. A MDS dated [DATE] indicated the diagnoses remained current. Review of Resident R4's care plan revised on 8/3/21, indicated Resident R4 required transfer with the sit to stand lift and assistance of two staff. Review of an incident report dated 7/7/23, indicated that after transferring Resident R4 to the toilet with the sit to stand and two staff, NA Employee E6 did not call for help to transfer the resident with the sit to stand back to her wheelchair and Resident R4 fell to the floor when she could not hold onto the bar of the sit to stand. Resident R4 was assessed and no injuries occurred due to the unsafe transfer. During an interview on 8/15/23, at 2:15 p.m., the Nursing Home Administrator confirmed that the facility failed to provide an environment that was free of accident hazards. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201,18(e)(1) Management. 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 211.10(d) Resident care policies.

Based on review of facility policy, clinical records, incident reports, facility documents, employee statement, and staff interviews, it was determined that the facility failed to make certain that a provided a safe transfer, for one of two residents reviewed (Resident R1). This was identified as past non-compliance for Resident R1. Findings include: Review of the facility policy Transporting Residents last reviewed on 10/30/22, indicated that each resident that uses a wheelchair will have appropriate leg rests on their wheelchair. If a resident self-propels in wheelchair, leg rests may be removed but must be in place if the resident is pushed in the wheelchair. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses which included a left hip replacement and heart disease. Additional diagnoses included anxiety disorder, communication deficit, history of falls and upper gastric bleed. A Minimum Data Set (MDS-periodic assessment of resident care needs) dated 11/27/22, indicated the diagnoses remained current. Review of Resident R1's current plan of care dated from 5/9/19, and revised on 10/22/20, indicated Resident R1 has limited physical mobility and requires assistance and is totally dependent on one staff for locomotion. Review of a facility document dated 12/16/22, indicated that Resident R1 was in her wheelchair. Nurse Aide Employee E1 was transporting Resident R1 to the shower and Nurse Aide Employee E1 was behind her and pushed the wheelchair, which had no leg rests in place, through the threshold of her room and felt a bump and Resident R1 went forward out of her wheelchair and onto the floor. Review of the Nurse Aide Employee E1 written statement dated 12/16/22, stated that when she pushed the resident through the doorway of her room, the resident went face first onto the floor and no leg rests were on the wheelchair. During an interview on 1/27/23, at 9:37 a.m. Nurse Aide Employee E1 stated the same as above and stated that she should have had leg rests on wheelchair and she was provided education on 12/19/22, regarding using leg rests when transporting residents. During an interview on 1/27/23, at 9:24 a.m. the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that the facility failed to ensure that Resident R1 was not provided a safe transfer. This was identified as past non-compliance for Resident R1 The facility implemented a plan of correction that included the following: -Immediate suspension of NA Employee E1 during the investigation. -Facility initiated education on 12/19/22, for all nursing staff including Registered Nurse's (RN's), Licensed Practical Nurses (LPN's), and Nurse Aides (NA's) to ensure that transportation of residents were performed safely and properly to prevent recurrence. -Audits of transfer status completed to ensure that they were up to date and accurate and that this information was reflected on the nursing assistant assignment sheets. - Monthly audits by DON or designee to determine if there are any issues related to transportation and use of leg rests. Continued audits through the safety committee. - Results from audits are submitted in the quarterly Quality Assurance Performance Improvement (QAPI) process for two quarters. The facility has demonstrated compliance with the above since 12/19/22. Information was verified via review of documentation provided by the facility. During an interview on 1/27/23, at 1:30 p.m. with the Director of Nursing (DON) and NHA and review of the facility's immediate actions, education, and review of the QAPI monitoring process, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring residents are provided proper devices during transport. During an interview on 1/27/23, at 10:20 a.m., Licensed Practical Nurse(LPN) Employee E2 stated that the facility immediately began retraining all staff on use of leg rests and leg rests were provided for all residents. During an interview on 1/27/23, at 10:23 a.m., LPN Employee E3 stated that she had training a couple days after it happened. During an interview on 1/27/23, at 10:30 a.m. Nurse Aide(NA)( Employee E4 stated that she had training a couple days after it happened and all residents have leg rests. During an interview on 1/27/23, at 10:43 a.m. NA Employee E5 stated that she had training for leg rest use but does not remember exactly when. During an observation on 1/27/23, at 10:15 a.m. Rehab Aide Employee E6 was transporting a resident to therapy with leg rests on. 28. Pa Code 201.14(a) Responsibility of licensee. 28. Pa. Code 211.12(d)(1) Nursing services. 28. Pa. Code 211.12(d)(5) Nursing services. 28. Pa Code 201.18(b)(1)(e)(1) Management.

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for three of 12 residents reviewed (Resident R15, R35, and R38). Findings include: Review of the facility policy Advanced Directive last reviewed 9/30/21 and 10/3/22, indicated that information will be provided upon admission if the resident has not formulated an advance directive. Review of the medical record indicated Resident R15 was readmitted to the facility on [DATE], with diagnoses that included diabetes, Alzheimer ' s Disease (type of brain disorder that causes problems with memory, thinking and behavior), and high blood pressure. Review of Resident R15 Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 10/27/22, indicated the diagnoses remain current. Review of the clinical record failed to reveal an advanced directive or documentation that Resident R15 was given the opportunity to formulate an Advanced Directive. Review of the clinical record indicated Resident R35 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, diabetes, and depression. Review of Resident R35's MDS dated [DATE], indicated the diagnoses remain current. Review of the clinical record failed to reveal an advanced directive or documentation that Resident R35 was given the opportunity to formulate an Advanced Directive. Review of the clinical record indicated Resident R38 was readmitted to the facility on [DATE], with diagnoses that included depression, stroke (blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients), difficulty swallowing, and anxiety. Review of Resident R38's MDS dated [DATE], indicated the diagnoses remain current. Review of the clinical record failed to reveal an advanced directive or documentation that Resident R38 was given the opportunity to formulate an Advanced Directive. During an interview on 11/17/22, at 2:40 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the clinical record did not include documentation that Residents R15, R35, and R38 were afforded the opportunity to formulate Advanced Directives. 28 Pa. Code: 201.29(a)(b)(c)(d)(j) Resident rights. Previously cited 11/4/21, 3/15/18, and 9/17/18.

Based on review of facility policy, clinical records, facility documentation and staff interviews, it was determined the facility failed to investigate one of four skin tears reviewed (Resident R41) Findings include: Review of facility policy Incident and Accident Reports dated 10/3/22, indicated that an incident is defined as any happening that is not consistent with the routine operation of the facility. The incident is documented on an Incident report form and forwarded to the supervisor for follow-up. Review of Resident R41's clinical record indicated was admitted [DATE] with diagnosis of Alzheimers (progressive mental deterioration due to degeneration of the brain), Dementia (chronic disorder of the mental processes caused by brain disease or injury marked by memory disorder, personality changes, and impaired reasoning) and Type 2 Diabetes Mellitus. Review R41's MDS assessment (minimum data assessment-periodic assessment of resident care needs) indicated the diagosis remained current. Review of nursing progress notes dated 10/19/22 indicated Resident R41 sustained a skin tear to right wrist, u shaped. No incident report was noted for Resident R41's skin tear. During an interview on 11/16/22, at 2:45 p.m. , the Director of Nursing confirmed that the facility failed to complete a skin tear investigation for Resident R41. 28 PA. Code: 201.14(a)responsibility of licensee 28 PA. Code: 201.18(e)(10 (4) Management

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels, and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for two of six Residents (Residents R15, and R20). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it's untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of the facility policy Hypoglycemia protocol last reviewed 9/30/21 and 10/3/22, indicated the purpose was to treat residents with blood sugars below 70. Review of the facility policy Hyperglycemia protocol last reviewed 9/30/21 and 10/3/22, indicated the purpose was to treat residents with elevated blood sugars. Review of the facility policy Change in Resident Status/Condition last reviewed 9/30/21 and 10/3/22, indicated the resident should have a head-to-toe assessment completed by a nurse, notify the physician of change in condition, and documentation will be made in the resident chart. Review of the medical record indicated Resident R15 was readmitted to the facility on [DATE], with diagnoses that included diabetes, Alzheimer's Disease (type of brain disorder that causes problems with memory, thinking and behavior), and high blood pressure. Review of Resident R15's Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 10/27/22, indicated the diagnoses remain current. Review of a physician order dated 9/13/22, indicated to check CBG before meals and at bedtime for seven days without coverage. Further review of a physician order dated 9/19/22, indicated to inject 34 units of insulin glargine (long-acting insulin administered by subcutaneous injection for the management of diabetes)at bedtime. Review of Resident R15's electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 10/24/22, at 8:08 p.m., CBG was noted to be 425. On 9/23/22, at 8:39 p.m., CBG was noted to be 433. On 9/21/22, at 7:21 p.m., CBG was noted to be 413. On 9/19/22, at 7:46 p.m., CBG was noted to be 415. On 9/19/22, at 3:15 p.m., CBG was noted to be 425. On 9/17/22, at 8:17 p.m., CBG was noted to be 431. On 9/14/22, at 7:18 p.m., CBG was noted to be 539. On 9/13/22, at 8:53 p.m., CBG was noted to be 456. Review of Resident R15's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 9/20/22, indicated to give diabetes medication as ordered and monitor/document side effects and effectiveness, and to monitor/document/report signs and symptoms of hyperglycemia and hypoglycemia to MD as needed. Review of a clinical record indicated Resident R20 was admitted to the facility on [DATE], with diagnoses that included diabetes, dementia (general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and high blood pressure. Review of Resident R20's MDS dated [DATE], indicated the diagnoses remain current. Review of a physician order dated 6/18/22, indicated to check CBG before meals with sliding scale insulin coverage. Further review of the physician orders revealed glucagon (a hormone that your pancreas makes to help regulate your blood glucose) one milligram (mg) injection as needed for hypoglycemia, and glucose gel 40% (used to treat low blood sugar ) as needed for hypoglycemia. Review of current active orders for Resident R20, indicated the above orders are still current. Review of Resident R20's eMAR revealed that the resident's CBG's were as follows: On 9/24/22, at 9:47 a.m., CBG was noted to be 65. On 9/17/22, at 10:56 a.m., CBG was noted to be 69. On 8/18/22, at 7:35 a.m., CBG was noted to be 66. On 7/28/22, at 8:56 a.m., CBG was noted to be 62. On 7/2/22, at 10:13 a.m., CBG was noted to be 62. Review of Resident R20's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, interventions were not documented, blood sugar was not rechecked, physician orders were not followed regarding facility's hypoglycemic protocol, and the physician was not notified of abnormal results on the above listed dates. Review of Resident R20's care plan dated 10/1/21, indicated to give diabetes medication as ordered and monitor/document side effects and effectiveness, and to monitor/document/report signs and symptoms of hypoglycemia to MD as needed. Review of the care plan indicated interventions were not in place at the time of hypoglycemic episodes until 10/13/22. During an interview on 11/18/22, at 8:40 a.m. Licensed Practical Nurse (LPN) Employee E1 stated for residents with hyper-/hypoglycemia she would follow protocol, assess the resident, notify the physician, and document in the residents' chart. During an interview on 11/18/22, at 8:50 a.m. Registered Nurse (RN) Employee E2 stated for residents with hyper-/hypoglycemia she would follow protocol, assess the resident, notify the physician, re-check the blood glucose, and document in the residents' chart. During an interview on 11/18/22, at 9:50 a.m., the Director of Nursing confirmed the facility failed to document hypo/hyperglycemic episodes, failed to follow hypoglycemic protocols, and failed to notify the MD of changes in condition for Residents R15, and R20. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(d) Resident Rights 28 Pa. Code 211.10 (c) Resident Care policies 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12 (d)(1)(2)(3) Nursing services 28 Pa. Code 211.12 (d)(5) Nursing Services

Based on review of facility policy and facility documents, observations and resident and staff interviews, it was determined that the facility failed to provide a grievance box and concern forms on one of two nursing units (South) and failed to provide residents with the grievance official contact information (name, business address, email address, and business telephone number) on two of two nursing units (North and South unit). Findings include: A review of the facility policy Concerns or Grievances last reviewed 10/1/21, indicated the facility will have grievance boxes accessible to residents for anonymous concerns and post in prominent locations throughout the facility the contact information for the grievance official. During an observation on 11/4/21, at 11:30 a.m. revealed the grievance official's contact information was not posted with the grievance forms on North nursing units. During an observation on 11/2/21, at 9:00 a.m. failed to reveal a grievance box or the grievance official's contact information on the South nursing unit. During an interview on 11/3/21, at 10:40 a.m. the Licensed Practical NurseNurse Employee E1 stated that residents on the South nursing unit can obtain a concern form from nursing staff and the completed forms are placed in a IN box for the Director of Nursing to pick up. During an interview on 11/4/21, at 11:27 a.m. Admissions Employee E2 confirmed South nursing unit does not have a grievance box available and the grievance official's information is not posted. During an interview on 11/4/21, at 11:30 a.m. the Director of Nursing confirmed the facility failed to provide a grievance box for the residents on South nursing unit and failed to post the grievance official's contact information on North and South nursing units. 28 PA Code: 201.18(e)(4) Management. 28 PA Code: 201.29(a)(b)(c) Resident rights.

Based on a review of facility policy, clinical record review and staff interviews, the facility failed to provide Activity of Daily Living (ADL) assistance of a shower and/or bed bath for one of five residents (Resident R32) Findings include: A review of the facility Bathing policy dated 10/1/21, indicated bathing is to cleanse the skin, prevent infection and promote comfort and be documented in the Point of Care electronic medical record. A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 9/15/21, Section G Functional Status, Question G0120 indicated that Resident R32 is unable to self-perform bathing and requires a support of one person. A review of the facility's shower schedule indicated that Resident R32, was to receive a shower on Tuesdays and Fridays during the evening shift. During an interview on 11/2/21, at 10:50 a.m. the Director of Nursing confirmed the clinical record did not include documentation that ADL assistance for showers was provided for one of five residents. 28 Pa. Code: 211.11(d)(e) Resident care plan. 28 Pa. Code: 211.12(3)(5) Nursing services.

Based on review of clinical records and staff interviews it was determined that the facility failed to allow end of life visitation for 1 of 6 residents (Resident R1). Findings include: Review of Center for Clinical Standards and Quality/Survey & Certification Group, Ref: QSO-20-39-NH dated 9/17/20, indicated that residents who are on transmission-based precautions for COVID-19 can receive visits in-person for [MEDICATION NAME] care situations. Review of the COVID-19 Symptomatic Line List provided by the facility indicated no residents diagnosed with [REDACTED]. The admission record indicated that Resident R1 was admitted on [DATE]. A review of the Quarterly Minimum Data Set (MDS - periodic assessment of care needs) dated 2/3/20, included [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident R1 was diagnosed with [REDACTED]. Review of a progress note dated 12/21/20, indicated that resident R1 as refusing to eat, take oral fluids and medications. Review of a progress note dated 12/22/20, indicated that resident R1 had poor response to stimuli and no oral intake. During an interview on 12/22/20, at 1:45 p.m. the Nursing Home Administrator confirmed that family members had made requests to visit and were denied. During an interview on 12/22/20, at 1:45 p.m. the Nursing Home Administrator confirmed that family members were was denied [MEDICATION NAME] care visitation rights at a time when the Resident R1 was actively dying. 28 Pa. Code 201.29(J): Resident rights.

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to make certain that physician visits were conducted at least every 60 days after the first 90 days of admission for six of 10 residents reviewed (Resident R1, R2 R3, R4, R5 and R6). Findings include: Review of facility policy Physician Visit Log dated 6/17/19, and last reviewed by the facility on 6/22/20, indicated that residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. The Admission Record indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS-periodic assessment of care needs) dated 4/10/20, included an additional [DIAGNOSES REDACTED]. A review of the physician progress notes [REDACTED]. The Admission Record indicated that Resident R2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE], included the same diagnoses. A review of the physician progress notes [REDACTED]. The Admission Record indicated that Resident R3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Significant Change MDS dated [DATE], included the same diagnoses. A review of the physician progress notes [REDACTED]. The Admission Record indicated that Resident R4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE], included the same diagnoses. A review of the physician progress notes [REDACTED]. The Admission Record indicated that Resident R5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Annual MDS dated [DATE], included the same diagnoses. A review of the physician progress notes [REDACTED]. The Admission Record indicated that Resident R6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Annual MDS dated [DATE], included the same diagnoses. A review of the physician progress notes [REDACTED]. During an interview on 7/27/20, at 3:10 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that Residents R1, R2, R3, R4, R5 and R6 were seen by a physician at least once every 60 days as required. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 8/9/19. 28 Pa. Code 211.2(a)(d)(2) Physician services.

Based on a review of clinical records, facility documents and manufacturer instruction and staff interview, it was determined that the facility failed to provide appropriate assistance and assistive devices to prevent actual harm resulting from falls (facial laceration) for two of five residents (Resident R49 and R23). Findings include: Review of the facility policy Fall Prevention last reviewed 6/17/19, previously reviewed 7/18/18, indicated that the facility will provide guidelines for fall prevention strategies for residents identified to be at risk to fall. During an interview on 8/9/19, at 10:30 a.m. the Director of Therapy Employee E12 confirmed that all residents who require a wheelchair are provided one upon admission, and all wheelchairs are issued with foot rests. The Director of Therapy Employee E12 further confirmed that foot rests may be removed for a resident to self-propel, but that staff should not transport a resident without utilizing the foot rests. The Admissions Record Report indicated that Resident R49 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment (MDS - periodic assessment of care needs) dated 4/5/19, indicated these [DIAGNOSES REDACTED]. Review of the care plan dated 4/4/19, indicated Resident R49 was at risk for falls related to confusion, gait/balance problems, incontinence, poor communication/comprehension, and being unaware of safety needs. Review of the facility Incident and Accident Report dated 6/20/19, indicated that at 6:45 a.m. Resident R49 was in wc being pushed into dining room. She planted her feed and went out of the wc hitting her head. Forehead was bleeding. L (left) leg was externally rotated and painful to touch. The incident further indicated that Resident R49 was cognitively impaired and was previously known to plant their feet (during transport). Review of an Employee witness statement dated 6/20/19, revealed that Nurse Aide (NA) Employee E11 indicated that she had asked Resident R49 to pick up her feet, and that she had but put them down again. NA Employee E11 again asked Resident R49 to pick up her feet, and the resident put them down again. Nurse's note dated 6/21/19, created 8/9/19, indicated that Resident R49 had an injury to the left side of her forehead, and was transferred via emergency services to Presbyterian Hospital Trauma Center. Review of the 6/21/19, Emergency Department documentation indicated that Resident R49 was treated for [REDACTED]. Resident R49 was ordered [MEDICATION NAME] 875mg/125mg (an antibiotic), a mandatory follow-up with an oral/maxillofacial surgeon, and a trauma clinic follow-up appointment to be scheduled as soon as possible. The Admissions Record Report indicated that Resident R23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment (MDS - periodic assessment of care needs) dated 3/11/19, indicated these [DIAGNOSES REDACTED]. Review of the care plan dated 4/15/19, indicated that Resident R23 is at risk for falls related to confusion, gait/balance problems, and being unaware of safety needs. Review of the facility Incident and Accident Report dated 6/2/19, indicated that at 8:00 p.m. cna was pushing resident (Resident R23) in wheel chair when residents foot caught the ground; resident landed on left side forehead. The incident further indicated that Resident R23 was cognitively impaired and indicated the injuries to be a hematoma to the left forehead and a laceration to the left cheek. Review of an Employee witness statement dated 6/2/19, revealed that Nurse Aide (NA) Employee E13 indicated that she was wheeling resident (Resident R23) down the hall to go to bed somehow her feet got stuck and she fell forward to floor. Review of a facility Incident and Accident Report dated 7/20/19, involving Resident R23 indicated that at 8:40 p.m. agency cna was wheeling resident down hallway to bed and blanket caught in wheel & she slipped out of w/c. The incident further indicated that Resident R23 was cognitively impaired and indicated the injuries to be a hematoma to the left forehead and a laceration to the left cheek. Review of an Employee witness statement dated 7/20/19, revealed that Nurse Aide (NA) Employee E14 indicated that she was wheeling resident (Resident R23) to bed and the blanket got caught in the wheel, resident slipped out of wheelchair. During an interview on 8/9/19, at 12:40 p.m. the Director of Nursing confirmed that the facility failed to provide appropriate assistance and assistive devices (foot rests) to Resident R49 and R23 and failed to prevent actual harm (laceration that required 25 sutures) to Resident R49. The facility failed to make certain that Resident R43 was provided assistive devices to prevent falls resulting in actual harm. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited: 8/18/17, 6/26/18, 3/5/19 28 Pa. Code 201.18(b)(1) Management. Previously cited: 8/18/17, 9/17/18 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited: 9/17/18 28 Pa. Code 211.10(d) Resident care policies. Previously cited: 8/18/17, 9/17/18 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 8/18/17, 6/26/18, 9/17/18.

Based on review of facility policy and clinical records and staff interviews, it was determined that the facility failed to accurately complete Minimum Data Set assessments for two of 34 residents (Resident R64 and R78). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (periodic assessments of resident care needs), dated (MONTH) (YEAR), indicated that Section O: 0100J, [MEDICAL TREATMENT] should be coded for peritoneal or [MEDICAL TREATMENT] which occurs at the nursing home or at another facility. MDS Section O: 0100K, Hospice care should be coded for residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. The facility policy entitled Interdisciplinary Team (IDT) dated 6/17/19, indicated that the IDT complies with the Resident Assessment Process (RAI). Review of the Admission MDS dated [DATE], indicated Resident R64 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. MDS Section O, indicated that Resident R64 was on hospice. Review of the Quarterly MDS dated [DATE], Section O:0100 indicated that Resident R64 was on [MEDICAL TREATMENT] however did not indicate that Resident R64 was on hospice. During an interview on 8/8/19 at 12:25 p.m., Registered Nurse Assessment Coordinator (RNAC) Employee E7 confirmed that the 7/8/19 MDS was inaccurate as Resident R64 did not receive [MEDICAL TREATMENT] but was on hospice. The RAI User's Manual, dated (MONTH) (YEAR), indicated that the MDS Section G: Residents with tube feeding, TPN, or IV fluids: - Code extensive assistance (1 or 2 persons): if the resident with tube feeding, TPN, or IV fluids did not participate in management of this nutrition but did participate in receiving oral nutrition. This is the correct code because the staff completed a portion of the ADL activity for the resident (managing the tube feeding, TPN, or IV fluids). - Code totally dependent in eating: only if resident was assisted in eating all food items and liquids at all meals and snacks (including tube feeding delivered totally by staff) and did not participate in any aspect of eating. Review of the clinical face sheet indicated that Resident R78 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a Dietary Progress Note dated 5/9/18, indicated that Resident R78 was NPO (nothing by mouth) and that 100% nutrition/ hydration via tube feeding. Review of the annual MDS dated [DATE], Section G: Activities of Daily Living Assistance (ADL) H: Eating indicated that Resident R78 required set-up help from one person to eat meals. Review of the 1/18/19, MDS Section K: 0510 Nutritional Approaches indicated that Resident R78 was only receiving feeding tube nutrition and did not include any other intake. During an interview on 8/9/19, at 10:28 a.m., RNAC Employee E7 and Assistant Director of Nursing Employee E6 confirmed that Resident R78 had been NPO for over a year and that the 1/18/19, MDS Section G: ADL Eating was inaccurate. 28 PA Code: 211.10(d ) Resident Care Policies. 28 PA Code: 211.12(d)(1)(5) Nursing Services.

Based on review of facility policy, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for five of five nurse aides (Employee E1, E2, E3, E4 and E5). Finding include: A review of the facility policy Education dated 6/17/19, indicated the facility will provide education to staff, and will comply with federal and state annual mandatory education requirements. Review of Nurse Aide (NA) Employees Employee E1, E2, E3, E4 and E5's education records with hire date greater than 12 months revealed the following: NA Employee E1 had a hire date of 2/27/17, with 2.0 hours in-service education between 2/27/18, and 2/27/19. NA Employee E2 had a hire date of 4/23/08, with 3.5 hours in-service education between 4/23/18, and 4/23/19. NA Employee E3 had a hire date of 4/25/01, with 3.5 hours in-service education between 4/25/18, and 4/25/19. NA Employee E4 had a hire date of 7/28/06, with 4.5 hours in-service education between 7/28/18, and 7/28/19. NA Employee E5 had a hire date of 5/8/09, with 3.5 hours in-service education between 5/8/18, and 5/8/19. During an interview on 8/8/19, at 2:35 p.m. the Nursing Home Administrator confirmed that the facility failed to provide the required 12 hours annual in-service education within 12 months of their hire date anniversary for NA Employee E1, E2, E3, E4 and E5. 28 Pa. Code: 201.14(a) Responsibility of Licensee. 28 Pa. Code: 201.20(c) Staff Development.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain medications were administered as ordered by the physician for one of four residents (Resident R296). Findings include: A review of facility policy Medication Administration - General Guidelines dated 6/17/19, indicated medications will be administered in accordance with the written orders of the physician. A review of the clinical record indicated that Resident R296 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a physician order [REDACTED]. During an observation on 8/7/19, at 8:45 a.m. Unit Manager Registered Nurse Employee E10 administered 1000 mg of [MEDICATION NAME]. During an interview on 8/7/19 at 9:45 a.m. Unit Manager Registered Nurse Employee E10 confirmed that the wrong dose of [MEDICATION NAME] was administered and that the facility failed to make certain medications were administered as ordered by the physician for Resident R296. 28 Pa. Code 211.12 (c)(1)(3) Nursing Services.

Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to notify the resident representative for a change in condition for four of six residents (Resident R1,R2, R3, and R4). Findings included: A review of facility policy Change in Resident Status/Condition last reviewed 7/18/18, indicated the facility will notify the representative of changes in the resident ' s medical/mental condition. A review of the clinical record revealed Resident R1 was admitted to the facility on [DATE], and has a [DIAGNOSES REDACTED]. A review of the clinical notes indicated that on 1/13/19, Resident R1 was had a new instance of skin breakdown on her left heel, and a new order for [MEDICATION NAME] to be applied. A review of wound care provider documentation completed by the Certified Registered Nurse Practitioner indicated that Resident R1 was seen by their practice on 2/14/19. A review of the clinical record did not include documentation that a resident representative was notified of Resident R1's skin breakdown and subsequent provider visit. A review of the clinical record revealed Resident R2 was admitted to the facility on [DATE], and has a [DIAGNOSES REDACTED]. A review of the (MONTH) 2019 Incident/Accident Log indicated that on 1/3/19, between 09:00 a.m. and 10:00 a.m. and on 1/30/19, between 10:00 a.m. and 11:00 a.m. Resident R2 was found on the floor. A review of the clinical record did not include documentation that a resident representative was notified of Resident R2 being found on the floor on 1/3/19, and on 1/30/19. A review of the clinical record revealed Resident R3 was admitted to the facility on [DATE], and has a [DIAGNOSES REDACTED]. A review of the (MONTH) 2019 Incident/Accident Log indicated that on 1/16/19, between 04:00 p.m. and 5:00 p.m. Resident R3 was treated at the facility for a skin tear of unknown origin. A review of the clinical record did not include documentation that a resident representative was notified of Resident R3's skin tear. A review of the clinical record revealed Resident R4 was admitted to the facility on [DATE], and has a [DIAGNOSES REDACTED]. A review of the (MONTH) 2019 Incident/Accident Log indicated that on 2/6/19, between 10:00 p.m. and 11:00 p.m. Resident R4 was treated at the facility for a bruise of unknown origin. A review of the clinical record did not include documentation that a resident representative was notified of Resident R4's was notified of bruise of unknown origin. During an interview on 3/5/18, at 6:15 p.m. the Nursing Home Administrator (NHA) confirmed that documentation did not include notification of family or other representatives for Residents R1, R2, R3, and R4. 28 Pa. Code 201.14(a) Responsibility of Licensee.

Based on observations and staff interviews, it was determined that the facility failed to provide a dignified dining experience for 10 of 16 residents (Resident R15, R19, R20, R21, R30, R40, R43, R62, R85 and R254). Findings include: During observation of the lunch meal in the South dining room on 9/10/18, from 12:20 p.m. to 1:00 p.m. the following was observed: -Residents R15, R40, R43 and R85 were seated together at a table. Resident R85 received the lunch tray first at 12:25 p.m. and began to eat. Resident R62 joined the group at the table at 12:39 p.m. and at 12:40 p.m. received a lunch tray and began to eat. Resident R15 was served a lunch tray at 12:41 p.m. (16 minutes after the first resident was served.) Resident R43 was served a lunch tray at 12:42 p.m. (17 minutes after the first resident was served.) Resident R40 was served a lunch tray at 12:46 p.m. (21 minutes after the first resident was served.) -Residents R20 and R254 were seated together at a table. Resident R20 received the lunch tray at 12:32 p.m.and began to eat. Resident R254 was served the lunch tray at 12:43 p.m. (11 minutes after Resident R20.) During an observation of the lunch meal in the South dining room on 9/10/18, at 12:50 p.m. Nurse Aide (NA) Employee E2 stood while feeding Resident R19. Residents R21 and R30 were placed in hospital gowns over clothes to eat in the dining room. During interviews on 9/10/18, at 1:00 p.m. and on 9/12/18, at 9:00 a.m. NA Employee E3 and the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a dignified dining experience for Residents R15, R19, R20, R40, R43, R62, R85 and R254. 28 Pa. Code: 201.29(c)(d) Resident rights. 28 Pa. Code: 211.12(d)(5) Nursing services.

Based on review of facility policies, clinical record review, facility reports, and staff interviews, it was determined that the facility failed to properly transfer the resident via Hoyer Lift, resulting in Resident R9 sustaining a fracture for one of 14 residents reviewed (Resident R9). Findings include: The facility's, Abuse and Neglect Prevention policy dated 7/20/16, states, LGAR will do everything . to prevent resident abuse or neglect. The facility's, Lifting Machine Using a Portable policy dated 7/20/16, states, . two staff members are required to lift a resident using a manual lifting device. The Admission Record indicated that Resident R9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set assement (MDS- a periodic assessment of resident care needs) dated 8/2/16, included [DIAGNOSES REDACTED]. The MDS also included that Resident R9 was an extensive assist with two or more persons for bed mobility and transfers. A nurses' note dated 9/1/16, indicated that Nursing Assistant, Employee E7, reported L (left) hip was swollen L (left) hip edema (greater than) R (right) hip. Pain upon palpation (a method of feeling with the fingers or hands during a physical examination). Call to DR. to report Awaiting call back. A review of the facility documentation revealed that the, education for Nursing Assistant (Employee E7) stated that Employee E7, transferred a resident who was a 2 person transfer, via a Hoyer lift (assistive device that allows residents to be transferred between a bed and a chair). Employee E7, admitted to the Director of Nursing (DON) that he did transfer Resident R9 using the Hoyer lift by himself. At the end of Employee E7's shift, Resident R9 was found to have, swelling at the hip. A nurse's note dated 9/2/16, indicated that a mobile X-ray was completed onsite. Review of the 9/2/16 mobile X-ray indicated a left occult intertrochanteric fracture of the left femur (break in hip). A review of the, Employee Action Form completed following the facility's investigation into Employee E7's actions revealed Violation Type A violation #2 violating Health and Safety rules with unsafe conduct or unsafe acts, which jeopardize the health and safety of resident's resulting in injury. Review of the information dated 9/30/16, submitted by the facility, concluded that the left hip fracture was a result of the resident being transferred by only one person and the Hoyer lift. During an interview on 9/28/16, at 10:18 a.m. the Director of Nursing (DON) confirmed that the facility was aware of the incident since 9/1/16. During an interview on 9/28/16, at 10:19 a.m. the DON confirmed that Resident R9, was transferred incorrectly by one person using a Hoyer lift, and the facility failed to provide a safe transfer. 42 CFR 483.25(h) Free of Accident Hazards/supervision/devices. Previously cited 7/23/15. 28 Pa. Code 201.18(b)(1)(2)(e)(1) Management. Previously cited 7/23/15. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 8/31/15, 9/5/14. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited 9/5/14. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 8/31/15, 7/23/15, 9/5/14.