Every finding on record at Liberty Pointe Rehabilitation and Healthcare CTR

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on three of five nursing units. (Station 1, Station 2, Station 3) Findings include: Observations on January 13, 2026, from 9:45 a.m. through 1:00 p.m. and on January 14, 2026, from 8:00 a.m. through 12:00 p.m., revealed the following: The Station 1 dining room had dust and a black substance on ceiling tiles. The Station 1 activities room door didn't latch. The Station 1 central bathroom toilet ran continuously. The bathroom of room [ROOM NUMBER] had a loose doorknob. The half wall by the nurses' station in Station 2 had chipped paint along the length of the top of the wall. The ceiling in room [ROOM NUMBER] had dark stains and chipped paint There was a hole in the ceiling in room [ROOM NUMBER]. The window blind in room [ROOM NUMBER] did not close and there was no curtain on the window. The ceiling in room [ROOM NUMBER] over wardrobes had cracks and stains. In room [ROOM NUMBER], there was peeling paint and wallboard damage over the bed and a black stain on the ceiling. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(2.1) Management.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to implement interventions to prevent the spread of infection for two of 36 sampled residents. (Resident 7 and 20) Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions, last reviewed on February 13, 2025, revealed that staff were to implement Enhanced Barrier Precautions to prevent the spread of multidrug-resistant organisms for residents with specific diagnoses which included Extended-Spectrum Beta-Lactamase (ESBL) in urine, even if the resident has been colonized. Staff were to post clear signage on the door or wall outside of the resident's room indicating the type of precautions, the required personal protective equipment to wear, and the high-contact resident care activities that required the use of gown and gloves, such as bathing/showering, providing hygiene, changing briefs and linens, and assistance with toileting to prevent the spread of infections. Staff were to wear a gown and gloves during high contact resident care activities. Clinical record review revealed that Resident 7 was admitted to the facility on [DATE], with diagnoses that included abnormal findings in the urine, urinary tract infection, diabetes, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was alert and oriented, always incontinent of urine, required extensive assistance from staff for toileting, and was dependent on staff for bathing. Review of the care plan revealed that Resident 7 required Enhanced Barrier Precautions and was at risk for transmitting an infection due to ESBL in his urine. The intervention was for staff to wear gloves and gowns while assisting the resident with all high-contact activity. Observations on January 13, 2026, at 12:30 p.m., January 14, 2026, at 10:30a.m., and January 15, 2026, at 11:18 a.m., revealed that there was no sign posted on the resident's door indicating that Enhanced Barrier Precautions were in place for Resident 7 per the policy. Clinical record review revealed that Resident 20 was admitted to the facility on [DATE], with diagnoses that included end stage renal disease (kidney failure), diabetes, and muscle weakness. Review of the MDS assessment dated [DATE], indicated the resident was alert and required extensive assistance from staff for toileting. Review of the care plan revealed that Resident 20 required Enhanced Barrier precautions and had a hemodialysis catheter (hollow tube inserted into a large vein) on the right side of her chest. The intervention was for staff to wear gloves and gowns while assisting the resident with toileting. On January 13, 2026, at 10:52 a.m., a nurse aide (NA 1) was observed entering Resident 20's room and assisting him with toileting. NA 1 did not wear a gown to assist the resident. In an interview during the observation period, NA 1 stated that she should have worn a gown as she assisted Resident 20 with toileting. In an interview on January 16, 2026, at 9:30 a.m., the Director of Nursing confirmed that signage for Enhanced [NAME] Precautions should have been in place for Resident 7 and staff should have worn a gown to assist Resident 20 with toileting. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for three of 36 sampled residents. (Residents 20, 24, 147)Findings include: Clinical record review revealed that Resident 20 was admitted to the facility on [DATE], and had diagnoses that included end stage renal disease (kidney failure), diabetic retinopathy (damage to blood vessels in the eye), and diabetes. The Minimum Data Set (MDS) completed on December 11, 2025, indicated that the resident was alert and had a diagnosis of diabetic retinopathy. The Care Area Assessment (CAA) summary dated December 11, 2025, noted that the resident's vision problem was to be addressed in the care plan. There was no evidence that interventions to address Resident's 20's vision problem were included in the current care plan. Clinical record review revealed that Resident 24 was admitted to the facility on [DATE], and had diagnoses that included chronic obstructive pulmonary disease. The MDS completed on December 3, 2025, indicated that the resident was alert and had likely carious teeth and was occasionally incontinent of urine. The CAA summary dated December 3, 2025, noted that the resident's dental needs and urinary incontinence were to be addressed in the care plan. There was no evidence that interventions to address Resident's 24's dental needs and urinary incontinence were included in the current care plan. Clinical record review revealed that Resident 147 was admitted to the facility on [DATE], and had diagnoses that included hemiplegia (paralysis on one side) and muscle weakness. The MDS completed on September 16, 2025, indicated that the resident was alert and had no teeth. The CAA summary dated September 18, 2025, noted that the resident's dental needs were to be addressed in the care plan. There was no evidence that interventions to address Resident's 147's dental needs were included in the current care plan. In an interview on January 16, 2026, at 9:28 a.m., the Director of Nursing confirmed there was no documented evidence that the identified care areas were addressed in the identified care plans. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to assess a resident's capability to self-administer medications for one of 36 sampled residents. (Resident 121)Findings include: Review of facility policy entitled, Resident Self-Administration of Medication, last reviewed February 13, 2025, revealed that a resident was only to self-administer medications after the facility's interdisciplinary team had determined which medications may be self-administered safely. The resident's preference would be documented on the appropriate form and placed in the medical record. The results of the interdisciplinary team assessment were recorded on the Medication Self-Administration Assessment Form which was placed in the resident's medical record. When the interdisciplinary team determined that bedside or in-room storage of medications would be a safety risk to other residents, the medications of residents permitted to self-administer would be stored in the medication cart or medication room. Clinical record review revealed that Resident 121 had diagnoses that included metabolic encephalopathy (brain dysfunction) and diabetes. Review of the Minimum Data Set assessment, dated December 22, 2025, revealed that Resident 121's cognitive ability was intact and the resident required extensive assistance from staff for activities of daily living. Observations on January 13, 2026, at 10:15 a.m., January 14, 2026, at 10:00 a.m. and 1:00 p.m., and January 15, 2026, at 9:30 a.m., revealed a 16-ounce jar of zinc oxide ointment and an antifungal cream unsecured on the bedside table in Resident 121's room. In an interview on January 14, 2026, at 10:15 a.m., Resident 121 stated that she self-administered the antifungal cream daily and that staff applied the zinc oxide to her sacral area after incontinence care. There was no documentation to support that the facility had assessed Resident 121 for the ability to self-administer the antifungal cream. The medications were not secured in her room. In an interview on January 16, 2026, at 9:31 a.m., the Director of Nursing confirmed that Resident 121 was not assessed to self-administer medications, and the medications should not have been in the room. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, observation, resident interview, and staff interview, it was determined that the facility failed to ensure the call bell was accessible for one of 36 sampled residents. (Resident 14)Findings include: Clinical record review revealed that Resident 14 had diagnoses that included hemiplegia and hemiparesis (paralysis on one side of the body), history of stroke, limited range of motion, and chronic pain. Review of the Minimum Data Set assessment, dated January 12, 2026, revealed Resident 14 was alert and oriented, able to communicate needs to staff, and had limited range of motion to the left arm and leg. Review of the care plan revealed Resident 14 was at risk for falls related to a history of falls and required a two person assist with transfers, mobility, and activities of daily living. The interventions included that staff were to keep the call bell within reach. Observations on January 14, 2026, at 10:15 a.m., and 1:00 p.m., and January 15, 2026, at 9:49 a.m., revealed that the call bell was not within Resident 14's reach. The call bell was observed tied to the left side rail, on the resident's side with paralysis. In an interview on January 15, 2026, at 9:50 a.m., Resident 14 stated he would like to use his call button, but he did not know where it was. In an interview on January 16, 2026, at 9:20 a.m., the Director of Nursing confirmed that the call bell was not in reach for Resident 14 and it should have been. 28 PA Code 211.12 (d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to store food in a sanitary manner on two of five nursing units. (Stations 2 and 5)Findings include:Review of the facility policy entitled, Food: Safe Handling for Foods from Visitors, dated February 13, 2025, revealed that staff were to label foods that were intended for later consumption with the resident's name. Observation in the Station 2 resident nourishment room on January 14, 2026, at 12:25 p.m., revealed in the freezer there was one shrimp scampi meal and five popsicles that were not labeled with a name. In the refrigerator, there was a dish of pasta and meat sauce dated December 25, 2025. There was a store-bought container of chicken strips, an opened bottle of vegetable juice, and a container of beef and beans that were not labeled with a resident's name. Observation in the Station 5 resident nourishment room on January 14, 2026, at 8:40 a.m., revealed that there was an opened bottle of water, an opened container of ice cream cake, a bottle of green vegetable juice, and an opened package of frozen fruit bars in the freezer that were not labeled with a resident's name. There was an empty storage bag containing crumbs in the freezer door. In the refrigerator, there were three yogurts that had use-by dates of December 29, 2025, January 7, 2026, and January 11, 2026, and that were not labeled with a resident's name. There was one can of purchased coffee, an opened jar of jelly, an opened jar of eggplant ratatouille, a box of wafer cookies, and a box of snack cakes that were not labeled with a resident's name. There was a large Styrofoam cup of an unknown thick substance not labelled or dated. In an interview on January 15, 2026, at 2:15 p.m., the Administrator confirmed the resident nourishment rooms are for resident foods only and that staff should store their food elsewhere. CFR 483.60(i) Food Safety RequirementPreviously cited 12/12/2428 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management.

Based on observation, it was determined that the facility failed to maintain sanitary conditions and store food properly in the dietary department. Findings include: During an environmental tour of the dietary department on December 10, 2024, at 9:30 a.m., observations revealed the following: There was a large hole in the paneling on the back wall of the recycling area located in the dietary department. The convection ovens were soiled. The insides of the top and bottom oven doors were coated with grease. The bottom of the top oven was covered heavily with burnt debris and burnt food crumbs. There was a large metal scoop stored on the inside of the large bin that contained flour. There was debris on the floor alongside the wall near the steamer and dry goods bins. On the inside of the ice machine, there was a brown substance on parts of the lid. The brown substance was also on the left inside wall of the ice machine. There were five cracked floor tiles near the entrance way of the utility hallway that was located inside the dietary department. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on resident interview and observation, it was determined that the facility failed to provide a working call bell for two of 33 sampled residents. (Residents 4, 142) Findings include: During a resident group meeting conducted on December 11, 2024, at 10:00 a.m., Resident 4 stated that when she activated the call bell from her bed, the light outside the door did not activate. Resident 142 stated that when he activated the call bell from his bed, there was no sound or light, and that he must yell for assistance. Observations on December 11, 2024, at 11:15 a.m., revealed that when Resident 4 activated the call bell from her bed, no light was observed outside of her door. At 11:35 a.m., Resident 142 activated the call bell from his bed; no sound or light was observed. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.12(d) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of 33 sampled residents. (Resident 2) Findings include: Clinical record review revealed that Resident 2 had diagnoses that included dementia, hypertension, and chronic obstructive pulmonary disease. Review of the Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment and was dependent on staff for dressing. On November 10, 2024, a physician ordered for staff to apply compression stockings (Tubigrips) on bilateral legs for swelling. On December 10, 2024, at 11:45 a.m. and 12:44 p.m., and again on December 11, 2024, at 10:00 a.m. and 10:25 a.m., the resident was observed dressed and seated in her wheelchair in the dining room on the nursing unit without the Tubigrips in place. On December 11, 2024, at 10:30 a.m., the licensed practical nurse stated that staff was to put the Tubigrips on with morning care. In an interview on December 12, 2024, at 10:30 a.m., the Director of Nursing stated that staff was to apply the Tubigrips every day with morning care as ordered by the physician. CFR(s) 483.25 Quality of Care Previously cited 4/13/24 28 Pa.Code 211.22(d)(1)(5)Nursing services.

Based on facility policy review and clinical record review, it was determined that the facility failed to notify a resident's physician of changes in clinical condition for one of three sampled residents. (Resident 3) Findings include: A review of the facility policy entitled, Notification of Changes, last reviewed November 1, 2023, revealed that staff were to notify the physician and resident representative if there was a change in clinical condition. Clinical record review revealed that Resident 3 had diagnoses that included dementia, difficulty walking, and osteoporosis. According to the pain evaluation documentation during May 2024, the resident had either no pain or a pain rated as a 1 on a scale of one to ten. On May 13, 2024, at 7:30 p.m., a nurse noted that the resident fell and was found on her left side. That night at 11:17 p.m., a nurse noted that the resident's pain was rated a 3. The following morning at 6:03 a.m., the nurse noted that the pain level increased to a 6. At 7:18 a.m., the nurse noted that the resident was having pain in her left hip when she moved. There was no documentation that the facility notified the resident's physician of the increase in hip pain following the fall. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to evaluate effectiveness of pain medication consistent with professional standards for one of three sampled residents. (Resident 3) Findings include: Review of the facility policy entitled, Pain Management, Last reviewed November 1, 2023, revealed that when using medications to treat pain, nursing staff was to evaluate the effectiveness of the medication to ensure appropriate treatment. Clinical record review revealed that Resident 3 had diagnoses that included dementia, difficulty walking, and osteoporosis. Since September 24, 2021, the resident had an ongoing physician's order that staff administer a pain medication (acetaminophen 650 milligrams) as needed for mild pain (pain rated 1-3 on a scale of 1-10). On May 13, 2024, at 7:30 p.m., a nurse noted that the resident fell and was found on her left side. According to the Medication Administration Records (MARs), that night at 10:23 p.m., a nurse administered the acetaminophen for pain rated at a 3. There was no documentation that the nurse assessed the resident afterwards to determine if the medication was effective. Documentation on the MAR the following morning at 6:03 a.m., indicated that the resident's pain had worsened to a 6. The nurse again administered the acetaminophen despite the pain being more severe than mild. Additionally, there was no evidence that the nurse notified the physician to obtain orders for additional pain management appropriate to the severity of the resident's pain. During an interview on July 8, 2024, at 1:30 p.m., the Director of Nursing confirmed that nursing staff should have documented whether or not the pain medication was effective. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to accurately monitor weight changes for two of five sampled residents. (Residents CL1, 3) Findings include: Review of the facility policy entitled, Weight Monitoring, dated November 1, 2023, revealed that a weight monitoring schedule would be developed upon admission for all residents and that weights would be recorded at the time obtained. Newly admitted residents were to have their weight monitored weekly for four weeks. Clinical record review revealed that Resident CL1 was admitted to the facility on [DATE], with diagnoses that included dementia, diabetes, and adult failure to thrive. Review of Resident CL1's care plan revealed he had a potential nutritional problem with an intervention to weigh per physician's order and facility policy. On March 7, 2024, the physician ordered for staff to obtain weights weekly for four weeks. There was no documented evidence that Resident CL1 was weighed weekly on March 19 or 26, 2024. Clinical record review revealed that Resident 3 was admitted to the facility on [DATE], with diagnoses that included dementia, and dysphagia (difficulty swallowing). Review of the care plan revealed that Resident 3 had swallowing problem with an intervention to monitor weights per facility policy. Review of a nutrition assessment dated [DATE], revealed the dietitian recommended weekly weights for four weeks then monthly weights. There was no documented evidence that a weight schedule was developed upon admission or that Resident 3 was weighed weekly per dietitian recommendation and facility policy. In an interview on April 18, 2024 at 2:27 p.m., the Director of Nursing confirmed that there is no documented evidence that weights were obtained per physician orders, dietitian recommendation, or facility policy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, resident and staff interview, observation, and results of a test tray audit, it was determined that the facility failed to provide food that was palatable and at appetizing temperatures on three of five nursing units. (Stations one, three, and four) Findings include: A review of the facility policy entitled, Food: Quality and Palatability, last reviewed November 22, 2023, revealed that food would be palatable, attractive, and served at a safe and appetizing temperature. During interviews on February 22, 2024, from 10:28 a.m. through 10:50 a.m., Residents 1, 2, 3, and 4, stated that the food was often cold and not palatable. Results of a test tray audit conducted on February 22, 2024, at 12:35 p.m., revealed chicken at a temperature of 112 degrees Fahrenheit (F), stuffing at a temperature of 100 degrees F, and Brussels sprouts at a temperature of 100 degrees F. In an interview during this observation period, Dietary Director 1 stated that the hot foods should have achieved a temperature of 130 degrees F or higher. On February 22, 2024, from 12:45 p.m. through 1:10 p.m., Residents 5 and 6 had received lunch in their rooms and stated the hot food was cold and Resident 7 had received lunch in the dining room and stated it was cold which was consistently a problem. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observation and interview, it was determined that the facility failed to maintain sanitary conditions in the kitchen. Findings include: Observation during the kitchen tour on December 19, 2023, at 10:22 a.m., revealed the following: There was a container of mushrooms in the walk-in refrigerator that was dated December 5, 2023. The Regional Director of Dining Services stated that the food should have been discarded seven days after it was opened. In the dry storage room, there was a number ten can of mushrooms and the bottom of the can was bulging. There were number ten cans of fruit cocktail, cherry pie filling, and pitted prunes, that were dented. The cans were not stored in a separate area designated for dented cans. There was a bag of thickener powder in a plastic container, that did not have a lid on the container, and the bag was opened and not sealed. There was an accumulation of debris on the windowsill under the air conditioner. There were multiple cases of food items that were on the floor. The Regional Director of Dining stated that the food items were delivered on December 18, 2023, and remained on the floor since that time. There was an open package of pasta that was not dated. A piece of pipe that extended from the grease trap under the three-compartment sink was broken. The pipe was not covered, and the contents of the pipe were exposed to air. There was liquid and particles of debris on the bottom of two reach-in freezers. There were containers of dry cereal and a scoop used to dish the cereal was stored on top of the container. There was a large accumulation of ice on the shelves and floor of the walk-in freezer. The base cover of the fan was off and was on the shelf. The fan was leaking fluid onto food items and there was moisture and an accumulation of ice on boxes of potato tots, gluten free bagels, shrimp, and turkey breast. There was an open bag of pie shells on the shelf under the fan. There was an accumulation of liquid on the bag. There was an accumulation of a black substance in the grease trap and a dried substance on the front of the oven door under the stove top. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management.

Based on observation, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment on four of five nursing units. (Station 1, Station 2, Station 3, and Station 5) Findings include: Observation on December 20, 2023, at 11:58 a.m., revealed a ceiling tile outside of room [ROOM NUMBER] and inside of room [ROOM NUMBER] that was stained and bowing. Observation on December 19, 2023, at 10:39 a.m., revealed peeling paint in rooms [ROOM NUMBERS]. There was a brown stained ceiling tile in room [ROOM NUMBER]. In room [ROOM NUMBER], a ceiling tile was stained and bowing. Observation on December 19, 2023, at 10:28 a.m., revealed clear splatter on the wall under the television, a bent outlet cover, and missing wall panels that left metal bars exposed in room [ROOM NUMBER]. The ceiling vent in the hallway outside room [ROOM NUMBER] had an accumulation of dust. There were brown stained ceiling tiles in the hallway outside the shower room, in room [ROOM NUMBER], and room [ROOM NUMBER]. There was a cracked ceiling tile in room [ROOM NUMBER]. 28 Pa. Code 201.18(b)(3)(e)(1) Management.

Based on observation and staff interview, it was determined that the facility failed to provide maintenance services to ensure safe water temperatures on two of five nursing units. (Stations 2 and 5) Findings include: Observations of water temperature readings taken by Employee 1 (maintenance staff), using a facility thermometer, from 9:30 a.m., to 11:54 a.m., on December 20, 2023, revealed the following: The resident room [ROOM NUMBER] sink was 121.5 degrees Fahrenheit ( F). The resident room [ROOM NUMBER] sink was 127.0 F. The resident room [ROOM NUMBER] sink was 126.1 F. The sink in the shower room on Station 5 was 127.7 F. In an interview on December 20, 2023, at 12:20 p.m., the Administrator stated that hot water should be below 110 F and the temperatures were above that in rooms identified and the Station 5 shower room. 28 Pa. Code 201.18(b)(3)(e)(1) Management. 28 Pa. Code 205.63 (b)(c) Plumbing and piping systems required for existing and new construction.

Based on clinical record review and staff interview, it was determined that the facility failed to develop a care plan and interventions to meet each residents' needs as identified in the comprehensive assessment for two of 28 sampled residents. (Residents 101, 136) Findings include: Clinical record review revealed that Resident 101 had diagnoses that included mood disorder, major depressive disorder, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that Care Area Assessments (CAA) triggered cognitive loss/dementia and communication as problem areas to be care planned. Resident 101's current care plan did not include interventions to address cognitive loss/dementia and communication. In an interview on December 21, 2023, at 9:29 a.m., the Director of Nursing confirmed that there had been no care plan developed to address Resident 101's cognitive loss/dementia and communication. Clinical record review revealed that Resident 136 was admitted to the facility on [DATE], with diagnoses that included hypotension (low blood pressure), anxiety, and acute kidney failure. Review of the MDS assessment dated [DATE], revealed that the resident had an indwelling catheter. The CAA for this MDS triggered urinary incontinence and indwelling catheter as a problem area to be care planned. Observation on December 19, 2023, at 10:45 a.m., revealed Resident 136 laying in bed with an indwelling catheter intact. Resident 136's current care plan did not include interventions to address urinary incontinence and indwelling catheter. In an interview on December 21, 2023, at 12:12 p.m., the Director of Nursing confirmed that there had been no care plan developed to address Resident 136's indwelling catheter. CFR 483.10(c)(3)(i) Comprehensive Care Plans Previously cited 1/27/23 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a resident receiving an as needed psychotropic medication was provided with behavioral interventions prior to administration and that physician's orders included duration parameters and rationale for continued use for one of seven sampled residents on psychotropic medications. (Resident 136) Findings include: Clinical record review revealed that Resident 136 was admitted to the facility on [DATE], with diagnoses that included hypotension (low blood pressure) and anxiety and had a physician's order, dated November 21, 2023, for staff to administer a psychotropic medication (Xanax) every 12 hours as needed for anxiety. The current order for the Xanax failed to include a time frame for the continued use of the medication. There was no physician documentation that it was appropriate for the order to be extended beyond 14 days. Review of the medication administration records for November and December 2023, revealed that the medication was adminstered 11 times with no documentation to support that behavioral interventions were attempted. In an interview on December 21, 2023, at 11:33 a.m., the Director of Nursing confirmed that there was no time frame for the continued use of Resident 136's Xanax and no documented evidence that behavioral interventions were attempted prior to administration. 28 Pa. code 211.12(d)(1)(5) Nursing Services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of five sampled residents. (Resident CL1 ) Findings include: Clinical record review revealed that Resident CL1 had diagnoses that included end stage renal disease and post hemorrhagic anemia. A physician's order dated November 29, 2023, directed staff to administer an injection (epoetin alfa) one time a day every Monday, Wednesday, and Friday to treat the resident's anemia. A review of the December 2023, Medication Administration Records revealed that there was no evidence that staff administered the injections as ordered on December 1, 4, and 6, 2023. In an interview on December 8, 2023, at 11:56 a.m., the Director of Nursing confirmed that there was no documented evidence that Resident CL1 received the injections as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure a call bell was accessible for one of 25 sampled residents. (Resident 87) Findings include: Clinical record review revealed that Resident 87 had diagnoses that included muscle weakness and heart failure. The Minimum Data Set assessment dated [DATE], indicated that the resident was alert and oriented, and was dependent on staff assistance with activites of daily living. The ongoing care plan indicated the resident was at risk for falls and that the call bell should be kept within reach. On January 24, 2023, at 11:57 a.m., and 12:53 p.m., and on January 26, 2023, at 11:24 a.m., the resident's call bell was observed beside the bed and out of reach. The resident stated that the call bell could not be reached. In an interview on January 27, 2023, at 10:45 a.m., the Director of Nursing confirmed that Resident 87's call bell was not in reach. 28 Pa. Code 211.12(d)(5) Nursing services.