Every finding on record at Lifequest Nursing Center

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide care and services to maintain activities of daily living (eating) for one of 27 sampled residents. (Resident 35)Findings include:Clinical record review revealed that Resident 35 had diagnoses that included Parkinson's Disease and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had cognitive impairments and was dependent on staff for activities of daily living (ADL), including personal hygiene, dressing, and eating. According to the care plan, the resident had an ADL self-care deficit with an intervention for staff to assist the resident with eating and personal hygiene. Observations on April 28, 2026, at 12:30 p.m., revealed Resident 35 in bed with his lunch tray. Resident 35 was attempting to feed himself, spilling food onto his chest/clothes. At 12:50 p.m., staff entered and stood next to Resident 35, fed him a few spoonfuls, and exited at 12:53 p.m. Resident 35 continued to attempt to feed himself, using his fingers, and spilling food down his face and onto his chest and clothing. Resident 35 was not assisted with the remainder of his meal. At 1:09 p.m., Resident 35 asked a nurse aide for help. The nurse aide left the room and returned at 1:20 p.m., and laid the resident down, the nurse aide did not assist Resident 35 to clean his face or chest/clothing that was stained with food.In an interview on April 30, 2026, at 3:53 p.m., Licensed Practical Nurse (LPN) 1 stated that Resident 35 was totally dependent on staff assistance for meals.In an interview on May 1, 2026, at 11:10 a.m., the Administrator and Registered Nurse Assessment Coordinator (RNAC) also confirmed that Resident 35 was dependent on staff for assistance with meals.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and interview, it was determined that the facility failed to provide restorative nursing services to improve or maintain range of motion on a consistent basis for one of 27 sampled residents. (Resident 35) Findings include:Clinical record review revealed that Resident 35 had diagnoses that included Parkinson's Disease, muscle weakness and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had cognitive impairments and was dependent on staff for activities of daily living (ADL), including personal hygiene and eating. According to the care plan, the resident had an ADL self-care deficit with an intervention for staff to assist the resident with ADL's. On January 24, 2026, a Restorative Nursing Program (RNP) for passive range of motion during morning and evening care was recommended for Resident 35. Review of Resident 35's clinical record revealed there was a lack of documentation to support that the resident was offered or provided the passive range of motion RNP for 14 out of the last 30 days.In an interview on May 1, 2026, at 12:15 p.m., the Administrator confirmed that there was a lack of documented evidence that Resident 35 was offered the restorative nursing program with morning and evening cares.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and facility documentation review, it was determined that the facility failed to ensure that staff provided adequate supervision in order to prevent falls for one of six residents at risk for falls. (Resident 102)Findings include:Clinical record review revealed that Resident 102 had diagnoses that included dementia, weakness, abnormalities of gait and mobility, and repeated falls. The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired. A review of the care plan identified that the resident was at risk for falls. Review of the care plan further indicated that Resident 102 had an activities of daily living self care performance deficit with an intervention for staff to assist with ambulation. Review of a fall risk assessment dated [DATE], identified that Resident 102 was a high risk for falls.Review of facility documentation revealed that on December 29, 2025, the resident had fallen in the common area ambulating without assistance. On January 2, 2026, Resident 102 fell attempting to sit in a recliner another resident was occupying. On January 9, 2026, the resident fell again in the common area ambulating without assistance. On January 11, 2026, the resident fell in her room ambulating to the bathroom. On January 12, 2026, Resident 102 was lowered to the ground in the common area. On January 15, 2026, Resident 102 placed herself on the floor from a chair. On February 17, 2026, Resident 102 was found on the floor in the hallway. On February 26 and 27, 2026, Resident 102 was found on the bathroom floor. On March 5, 2026, the resident was found on the floor outside of her room doorway. On March 11, 2026, the resident fell again attempting to sit in a recliner another resident was occupying. On March 24, 2026, the resident fell against the fire door. On March 25 and 28, 2026, Resident 102 fell again trying to occupy a recliner chair. On March 30, 2026, the resident was found crawling on the floor. On April 1, 2026, Resident 102 fell once again trying to sit on a recliner chair. On April 4, 2026, Resident 102 fell twice, once outside and once bending to pick something up. On April 5 and 19, 2026, Resident 102 was again attempting to sit in a recliner chair and fell. On April 30, 2026, Resident 102 was again attempting to sit in a recliner that another resident was occupying and fell. Review of nursing documentation revealed that on February 15, 2026, Resident 102 was noted to be wandering and difficult to redirect. On February 18, 2026, Resident 102 was noted to be wandering non stop, pulling blankets off of other residents and nearly falling on multiple occasions while trying to move chairs and tables. On February 27, 2026, the resident was noted to be agitated. On March 4, 2026, Resident 102 was noted to be agitated and roaming non stop, moving chairs, nearly falling on several occasions, getting into the trash, and pulling things off the wall. On March 9, 2026, the resident was noted as anxious and wandering, and hard to redirect. On March 11 and 31, 2026, Resident 102 was noted to be very restless, anxious, and agitated and unable to be redirected. On April 1 and 2, 2026, Resident 102 was noted to be very agitated with an unsteady gait. On April 5, 2026, the resident was found self ambulating in the bathroom and urinating on the floor. On April 14, 2026, the resident was noted to ambulate with an unsteady gait, attempting to pick things up off the floor that were not there, and be restless. The facility failed to provide adequate supervision to prevent falls for a resident who had an unsteady gait requiring assistance from staff for walking and impulsive behavior and had fallen 21 times in four months.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one of 27 sampled residents. (Resident 10)Findings include:Clinical record review revealed that Resident 10 had diagnoses that included opioid dependence and chronic pain syndrome. On March 18, 2026, the physician ordered for the resident to receive the narcotic pain medication, oxycodone-acetaminophen, every six hours as needed for moderate to severe pain. Review of Resident 10's care plan revealed the resident had chronic pain with an interventions for staff to provide rest periods, quiet, and a calm environment to facilitate relief when experiencing pain. Review of Medication Administration Records revealed that the resident received the as needed narcotic (oxycodone-acetaminophen) without documented evidence that non-pharmacological interventions were attempted prior to administration seven times in March 2026, and 18 times in April 2026.28 Pa. Code 211.9(a)(1) Pharmacy services.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility records and staff interview, it was determined that the facility failed to electronically submit direct care staffing information in the Payroll Based Journal (PBJ) system for one of one quarter reviewed. (Quarter one)Findings include:Review of a PBJ staffing data report revealed that the facility did not submit data for Quarter one (October 1, 2025, to December 31, 2025). In an interview on April 30, 2026, at 1:50 p.m., the Administrator confirmed that the facility failed to submit staffing data to the Center for Medicare and Medicaid Services (CMS) for the PBJ report for Quarter one of 2026.28 Pa. Code 201.18(b)(3) Management.

Based on observation, it was determined that the facility failed to store food and equipment under sanitary conditions in the kitchen and on one of four nursing units. (Unit DEF) Findings include: A tour of the main kitchen on April 2, 2025, at 10:27 a.m., revealed the following: There was no hand soap at a handwashing station. There was an uncovered garbage can next to a food preparation surface. Garbage was piled over the top of the garbage can and in contact with the table top can opener. There was an accumulation of dust on the vent cover to the ice machine. There were particles of debris, rust, and water on the top of the ice machine. In dry storage, there was a dented can of pumpkin on the can rack. There was a container of cereal with a use by date of March 22, 2025. There was a container of cous cous with a use by date of November 2024. There was an uncovered garbage can, that contained garbage, by the beverage station. Boxes of gloves were stored over the garbage can. Clean gloves were hanging out of the boxes and in contact with the garbage can. There was a rack of clean mugs that were used for resident trays stored next to the uncovered garbage can. There was an accumulation of a brown substance on the cover to the flour bin. There was a pan of pickles in the walk in refrigerator, the plastic wrap was not covering the pan and the items were left open to air. In the walk in freezer, there was a package of turkey bacon and a box of ground beef patties. The packages had been opened, were not re sealed, and the contents were left open to air. Observation of the microwave on the DEF nursing unit on April 3, 2025, at 12:53 p.m., revealed an accumulation of splatter from unknown substances on the inside of the door and inside walls of the microwave. The top of the inside of the microwave was discolored, chipped, and corroded. 28 Pa. Code 210.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(2.1) Management

Based on clinical record review and observation, it was determined that the facility failed to ensure that safety interventions for falls were in place for one of 22 sampled residents. (Resident 2) Findings include: Clinical record review revealed that Resident 2 had diagnoses that included dementia and hemiplegia (paralysis to one side of the body). The Minimum Data Set assessment dated [DATE], revealed that Resident 2 required staff assistance for bed mobility and transfers. Review of progress notes dated October 7, November 8, and December 1, 2024, and March 11, 2025, revealed that the resident was found on the floor in her room by her bed. Review of the care plan identified that the resident was at risk for falls related to poor communication and cognitive loss. The intervention was for staff to place the bed in the low position with floor mats on both sides of the bed while the resident was in bed. Observations on April 1, 2025, at 10:10 a.m., and 2:14 p.m., April 2, 2025, at 10:50 a.m., and April 3, 2025, at 9:00 a.m., revealed Resident 2 was in bed. The floor mats were not in place. In an interview on April 3, 2025, at 11:30 a.m., the Director of Nursing confirmed that the fall mats should have been in place. 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 attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for two of 22 sampled residents. (Residents 13 and 87) Findings include: Review of the facility policy entitled, Pain Management, last reviewed January 14, 2025, revealed that non-pharmacological interventions should be attempted prior to administration of pain medication that was prescribed on an as needed basis. Clinical record review revealed that Resident 13 had diagnoses that included dementia, abnormalities of mobility, and pain in right arm and left lower leg. A physician's order dated February 10, 2025, directed staff to administer tramadol (a pain medication) every six hours, as needed, for moderate pain. Review of the medication administration records (MARs) for February and March 2025, revealed no evidence that staff attempted non-pharmacological interventions to alleviate pain prior to the administration of tramadol on 17 occasions in February and 26 occasions in January. There were no documented refusals of non-pharmacological interventions. Clinical record review revealed that Resident 87 had diagnoses that included dementia, weakness, and low back pain. A physician's order dated February 7, 2025, directed staff to administer tramadol every eight hours, as needed, for all levels of pain. Review of the MARs for February and March 2025, revealed no evidence that staff attempted non-pharmacological interventions to alleviate pain prior to the administration of tramadol on four occasions in February and 12 occasions in March. There were no documented refusals of non-pharmacological interventions. In an interview on April 3, 2025, at 12:21 p.m., the Director of Nursing confirmed that non- pharmacological interventions should be documented in the MAR and that there was no evidence that staff attempted non-pharmacological interventions prior to the administration of the as needed pain medication. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of the Resident Assessment Instrument (RAI) user manual, clinical record review, and staff interview, it was determined that the facility failed to complete Minimum Data Set (MDS) assessments in accordance with specified time frames for two of 22 sampled residents. (Residents 92 and 360) Findings include: Review of the Long Term Care Facility RAI user manual dated October 2024, which provided instructions and guidelines for completion of federally required MDS assessments, revealed that admission assessments were to be completed no later than 13 days after the resident's entry date and that a quarterly assessment must be completed every quarter. Clinical record review revealed that Resident 92 had a quarterly MDS assessment due for the reference date of January 24, 2025. There was no evidence that a quarterly assessment was completed as per the time requirements. Clinical record review revealed that Resident 360 had an admission MDS assessment dated [DATE], noted as still in progress and had not been completed as per the time requirements. In an interview on April 3, 2025, at 11:24 a.m., the Administrator confirmed that the MDS assessments were not completed within the required time frames.

Based on clinical record review, observation, resident interview, and staff interview, it was determined that the facility failed to implement physician's orders for one of seven sampled residents. (Resident 2) Findings include: Clinical record review revealed that Resident 2 had diagnoses that included hypertension (high blood pressure), congestive heart failure, and chronic kidney disease. A physician's order dated August 23, 2024, directed staff to apply elastic stockings to the lower extremities every morning for fluid retention. This was scheduled to be done on the night shift at 6:00 a.m. On October 1, 2024, at 12:02 p.m., the resident was observed out of bed in her wheelchair. The elastic stockings were not in place. The resident stated that she was not wearing the elastic stockings, staff had not offered to apply them, and had not applied them in a while. In an interview on October 1, 2024, at 1:13 p.m., the nurse aide (NA 1) assigned to Resident 2 stated that the elastic stockings were not in place. At 1:27 p.m., the resident was again observed in her wheelchair; the elastic stockings were not in place. Physician's orders dated August 23, 2024, and September 18, 2024, directed staff to obtain the resident's weight daily. Review of the resident's treatment administration record for September 2024, revealed no evidence that staff had obtained the resident's weight on September 3, 6, 8, 9, 12, 13, or 24, 2024. There was no evidence that the resident refused. In interviews on October 1, 2024, at 1:40 p.m. and 2:04 p.m., the Director of Nursing confirmed that the resident's elastic stockings were not applied and the daily weights were not obtained as ordered. 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 document the rationale and justification for the continued use of as needed (PRN) psychotropic medications for four of five residents sampled who had orders for anti-psychotic medications. (Residents 4, 10, 16, 77) Findings include: Clinical record review revealed that Resident 4 had diagnoses that included dementia and had a physician's order dated October 2, 2023, for staff to administer a psychotropic medication lLorazepam) every four hours PRN for anxiety. The current order for the lorazepam failed to include a time frame for the continued use of the PRN 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 (MARs) for March, April, and May 2024, revealed the PRN medication was administered three times. Clinical record review revealed that Resident 10 a had diagnosis of dementia. On October 31, 2023, a physician ordered for staff to administer an anti-anxiety medication (ativan) every six hours PRN for anxiety. The current order for the ativan failed to include a time frame for the continued use of the PRN medication. There was no physician documentation that it was appropriate for the order to be extended beyond 14 days. Review of the MAR for April 2024, revealed that the PRN medication was administered one time. Clinical record review revealed that Resident 16 had diagnoses that included major depressive disorder and anxiety and had a physician's order dated March 29, 2024, for staff to administer a psychotropic medication (trazodone) PRN at night for insomnia. The current order for trazodone failed to include a time frame for the continued use of the medication. There was no physician documention that it was appropriate for the order to be extended beyond 14 days. Clinical record review revealed that Resident 77 had a diagnosis of Alzheimer's disease. On October 10, 2023, a physican ordered for staff to administer an anti-anxiety medication (ativan) every six hours PRN for agitation/restlessness. The current order for the Ativan failed to include a time frame for the continued use of the PRN medication. There was no physician documentation that it was appropriate for the order to be extended beyond the 14 days. Review of the MARs revealed that the PRN medication was given two times in December 2023 and two times in January 2024. Further review of the MARs revealed that the PRN medication was given eight times in February 2024, nine times in March 2024, and three times in April 2024. In an interview on May 9, 2024, at 9:30 a.m., the Director of Nursing confirmed that there was no time frame for the continued use of the previously mentioned PRN psychotropic medications in Residents 4, 10, 16, and 77. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that pharmacy recommendations were obtained and acted upon in a timely manner for two of 19 sampled residents. (Residents 10, 85) Findings include: Review of the facility policy entitled Medication Regimen Reviews, last reviewed January 9, 2024, revealed that the consultant pharmacist was to perform a medication regimen review (MRR) for every resident in the facility who was receiving medication. The consultant pharmacist was to provide a written report to the facility and attending physicians for each resident identifed as having a medication irregularity. An irregularity referred to the use of medication that was inconsistent with accepted pharmaceutical services standards of practice. The physician was to document in the medical record that the irregularity had been reviewed and what action was taken to address it. Clinical record review revealed that Resident 10 had a diagnosis of dementia and was care planned for the use of anti-psychotic medications. On November 3, 2023, a physician ordered an anti-psychotic medication (Seroquel) at night for generalized anxiety disorder. On January 26, 2024, a licensed pharmacist indicated that the diagnosis of generalized anxiety disorder was not a typical diagnosis to justify the use of an anti-psychotic medication. The pharmacist recommended to consider choosing a diagnosis that was considered appropriate for the use of the Seroquel. On February 2, 2024, a physician acknowledged the MRR and indicated that the diagnosis was to be psychosis for the continued use of the Seroquel. There was no documented evidence that the diagnosis for the continued use of the Seroquel was changed on the physician's order as recommended by the pharmacist. Clinical record review revealed that Resident 85 was admitted to the facility on [DATE], and was care planned for the use of an anti-psychotic medication. On October 31, 2023, a physician ordered an anti-psychotic medication (Seroquel) every day for behaviors. On November 20, 2023, a physician ordered an additional dose of the Seroquel at night for behaviors. On January 26, 2024, a licensed pharmacist indicated that the resident was receiving the Seroquel but lacked an allowable diagnosis to support the continued use of the anti-psychotic medication. The pharmacist recommended that the diagnosis of depression with psychotic features be used to justify the continued use of the Seroquel. On February 6, 2029, a physician acknowledged the MRR, but failed to include a response to the recommendation. There was no documented evidence that the diagnosis for the continued use of the Seroquel was changed on the physician's order as recommended by the pharmacist. In an interview on May 9, 2024, at 11:00 a.m., the Director of Nursing stated that the diagnosis had not been changed to reflect the pharmacist recommendation for the continued use of the Seroquel for Resident 10 and 85. 28 Pa.Code 201.18(e)(1)(3) Management. 28 Pa. Code 211.9(k) Pharmacy services. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on clinical record review, and resident and staff interview, it was determined that the facility failed to provide adequate and timely podiatry care for one of 19 sampled residents. (Resident 21) Findings include: Clinical record review revealed that Resident 21 was admitted to the facility on [DATE], with diagnoses that included spastic hemiplegia, (paralysis), cerebral palsy and muscle weakness. The Minimum Data Set assessment dated [DATE], indicated that the resident was alert and oriented. On April 19, 2024, a social worker noted that the resident was alert, oriented and able to be understood at all times. In an interview on May 7, 2024, at 11:17 a.m., Resident 21 stated that he wanted his toe nails cut and that he had not received any kind of foot care from a podiatrist since he had been admitted to the facility. Further review of the clinical record revealed that there was no documented evidence that he had been seen by a podiatrist since he had been admitted to the facility. In an interview on May 9, 2024, at 9:29 a.m., the Administrator confirmed that the resident had not been scheduled for any of the monthly podiatrist's visits since he had been admitted to the facility. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and observation it was determined that the facility failed to change respiratory equipment in accordance with facility policy and physician's orders for one resident receiving oxygen therapy out of 18 sampled residents. (Resident 11) Findings include: Review of the facility policy entitled, Respiratory Equipment, last reviewed January 27, 2023, revealed that all respiratory equipment was to be changed weekly and that all new equipment was to be labeled with the date it was changed. Clinical record review revealed that Resident 11 had diagnoses that included acute and chronic respiratory failure. On March 6, 2021, the physician ordered that staff administer continuous oxygen therapy to the resident change the equipment weekly. On July 11, 2023, at 1:00 p.m. through July 12, 2023, at 12:00 p.m. Resident 11's oxygen tubing was observed dated June 8, 2023. There was no documented evidence that facility staff gave the resident fresh oxygen tubing every week. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on clinical record review and staff and resident interviews, it was determined that the facility failed to provide assistance with bathing for two of 18 sampled residents. (Resident 28 and 52) Findings include: Clinical record review revealed that Resident 28 had diagnoses that included severe morbid obesity and diabetes. According to two Minimum Data Set (MDS) assessments dated March 3 and May 29, 2023, the resident required extensive assistance from staff for activities of daily living (ADLs). A review of the care plan revealed that the resident required assistance with hygiene and that staff was to provide a shower or bed bath twice a week. According to nurse aide records the resident did not receive a shower on her scheduled day on June 29, 2023. In an interview on July 13, 2023, at 2:08 p.m., Resident 28 stated that she was not always offered showers and she wanted to receive one. In an interview on July 14, 2023, at 10:55 a.m., the Director of Nursing confirmed that the resident wasn't offered a bath or shower on that date. Clinical record review revealed that Resident 52 has diagnoses of abnormal posture and difficulty walking. According to the MDS assessment dated [DATE], the resident required extensive assistance from staff for ADLs and was totally dependent on staff for bathing. According to nurse aide records, the resident was scheduled for a bath or shower on July 4 and 7, 2023, and did not receive one. In an interview on July 11, 2023, the resident stated that she had previous gone up to a month without a shower. In an interview on July 14, 2023, at 10:55 a.m., the Director of Nursing confirmed that there was no documented evidence that the resident was offered a shower in July 2023. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on interview and review of facility reports, it was determined that the facility failed to ensure that call bells were answered in a timely manner for two of four sampled residents. (Resident 1, 2) Findings include: Clinical record review revealed that Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident 1 required extensive assistance for bed mobility and toilet use, and was totally dependent on staff for transfers. Review of the care plan revealed Resident 1 had a self-care performance deficit and was at risk for falls. The interventions included that staff ensure the call bell was within reach and encourage use of the call bell for assistance. In an interview on April 23, 2021, at 12:00 p.m., Resident 1 reported a wait time of up to 30 minutes for staff to respond to the call bell once it was engaged. Review of facility call bell reports from April 15, 2021 to April 17, 2021, revealed response times for Resident 1's call light alarm of 12 minutes on three occasions and 16 minutes on one occasion. Clinical record review revealed that Resident 2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE], revealed Resident 2 required extensive assistance with activities of daily living. Review of the care plan revealed that Resident 2 had a self-care performance deficit and bladder incontinence (loss of bladder control). Interventions included that staff ensure the call bell was within reach and answered promptly. Review of facility call bell reports revealed a response time of 27 minutes for Resident 2's call light alarm on Monday April 12, 2021. During an interview on April 23, 2021, at 2:23 p.m., the Director of Nursing reported that staff was expected to respond to the call bell within five to eight minutes 28 Pa. Code 201.29(j) Patient Rights

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to minimize the potential for diversion of controlled substances ([MEDICATION NAME]) for one of 25 sampled residents. (Resident 47) Findings include: Review of the facility policy entitled, Controlled Substance Disposal, dated January 23, 2020, revealed that when a controlled substance was wasted or destroyed, it was to be done in the presence of two licensed nurses. Signatures of witnesses were to be entered on the controlled substances accountability record. Clinical record review revealed that Resident 47 had [DIAGNOSES REDACTED]. There was a physician's order to apply a [MEDICATION NAME] (a controlled substance) every third day for pain and to remove it per schedule with disposal to be verified by a second nurse. Review of the medication administration records for January 2020, and February 2020, and the facility's narcotic record book revealed that the narcotic ([MEDICATION NAME]) patch was applied and removed 12 times with no evidence that a witness was present for the removal. In an interview on February 12, 2020, at 11:38 a.m., the Administrator confirmed that there was a lack of documentation to support that a second nurse had signed as a witness for disposing of the narcotic. 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 ensure that adequate supervision to prevent unsafe wandering was provided for one of 25 sampled residents. (Resident 83) Findings include: Review of the facility policy entitled Wanderguard Process, dated January 23, 2020, revealed that residents identified at risk for elopement were to have a Wanderguard (an alarm device that sounds when a resident leaves the building to alert staff) placed directly on the wrist or ankle of the resident to ensure their safety. The policy further indicated that a picture of the resident was to be placed in the elopement book (a book containing photographs of all resident at risk for unsafe wandering which was kept in the receptionist's area) for identification of the residents who have Wanderguards. Clinical record review revealed that Resident 83 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated January 14, 2020, revealed that the resident had short and long term memory impairment. The elopement risk assessment dated [DATE], indicated that the resident was at high risk for wandering. Review of the admission summary note on January 3, 2020, revealed that the resident was confused, talked about going into the woods, and that nursing had placed a Wanderguard on his left ankle. The initial care plan identified that the resident was a risk for wandering and interventions included to ensure that the Wanderguard was in place and for staff to walk with the resident and redirect him. A nursing progress note dated January 10, 2020, at 4:26 p.m., indicated that the resident was found outside of the building with his Wanderguard in place. There was lack of documentation to show that nursing staff knew the location of the the resident at the time of the incident. In an interview on February 10, 2020, at 2:38 p.m., the front desk receptionist (Employee 1), stated that she had turned the door alarm off on January 10, 2020, when the elopement incident occurred at 4:13 p.m. without physically investigating the cause of the alarm to check if the resident who left the building was included in the elopement book. In an interview on February 11, 2020, at 3:03 p.m., the Nursing Home Administrator confirmed that staff failed to identify that a resident had left the building without supervision. 28 Pa. code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation and staff interview it was determined that the facility failed to provide services and treatment to prevent further limitations in range of motion or mobility for two of four sampled residents with limited range of motion. (Residents 61, 68) Findings include: Clinical record review revealed that Resident 61 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had memory impairment, required extensive assistance from staff for activities of daily living including dressing and had limitations in range of motion on both sides of her upper and lower extremities. Review of an occupational therapy discharge summary dated October 4, 2019, revealed that the resident was to wear orthotic devices to both hands for eight hours a day in order to prevent the worsening of flexion contractures. The occupational therapist further recommended that staff apply palm protectors to both hands. On September 27, 2019, a physician ordered that staff apply bilateral palm protectors at all times. Observation on February 9, 2020, at 9:30 a.m., 12:30 p.m., and 2:00 p.m., revealed that the resident was dressed and seated in her reclining geriatric chair without the palm protectors in place. In an interview on February 12, 2020, at 9:12 a.m., the Administrator stated that the resident was to have the palm protectors in place as ordered by the physician. Clinical record review revealed that Resident 68 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], indicated that the resident was alert and oriented, had limited range of motion of the lower extremity, and required staff assistance for transferring between surfaces. physician's orders [REDACTED]. In an interview on February 10, 2020, at 9:48 a.m., Resident 68 stated that she did not receive assistance from nursing staff to stand with the bar. In an interview on February 10, 2020, at 10:33 a.m., the nurse aide (NA1) assigned to Resident 68 stated that the resident was not provided restorative nursing services and that she was unaware of assisting the resident to stand with the bar. Review of the nurse aide task sheet revealed that although NA1 was unaware of the need to provide restorative nursing services for standing with the bar, she had documented that she completed it on January 6, 2020. CFR 483.25(c)(1)-(3) Increase/Prevent Decrease in ROM/Mobility Previously cited 3/22/19 28 Pa. Code 211.12.(d)(1)(5) Nursing services.

Based on clinical record review and observation, it was determined that the facility failed to ensure that resident dignity was promoted for seven of 25 sampled residents. (Residents 36, 37, 42, 59, 67, 77, 81) Findings include: Clinical record review revealed that Resident 36 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had memory impairment and required extensive assistance with activities of daily living. Review of the current care plan identified an intervention for staff to check the resident's nail length, trim and clean as necessary. Observation on February 9, 2020, at 9:45 a.m., and again at 12:05 p.m., revealed that the resident was dressed and in his wheelchair and his nails were long and jagged. Clinical record review revealed that Resident 37 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], indicated that the resident had an indwelling catheter and utilized a wheelchair. Observation on February 9, 2020, at 9:46 a.m., 11:40 a.m., and 2:00 p.m., revealed that the resident was dressed and in his wheelchair and the catheter bag was attached to the bottom of his wheelchair and was exposed. Clinical record review revealed that Resident 42 had [DIAGNOSES REDACTED]. The MDS assessment November 22, 2019, indicated that the resident required extensive assistance with personal hygiene. Observation on February 9, 2020, at 10:30 a.m., on February 10, 2020, at 9:30 a.m., and again on February 11, 2020, at 9:10 a.m., revealed that the resident was dressed and in his reclining geriatric chair and had excess facial hair and was unshaven. Clinical record review revealed that Resident. 67 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], indicated that the resident required extensive assistance from staff for activities of daily living. Observation on February 9, 2020, at 9:45 a.m., revealed that the resident was dressed and in his wheelchair and his nails were long, uneven and dirty. Clinical record review revealed that Resident 59 had [DIAGNOSES REDACTED]. The current care plan indicated a nutritional risk due to a history of difficulty swallowing and that staff were monitor chewing and swallowing functions during meals. Clinical record review revealed that Resident 77 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], indicated that the resident had memory impairment and required extensive assistance from staff for activities of daily living which included eating. Clinical record review revealed that Resident 81 had [DIAGNOSES REDACTED]. The current care plan indicated the residnt was at nutritional risk and an intervention was for staff to provide full assistance with meals. Observation on February 9, 2020, from 12:05 p.m. through 12:12 p.m., revealed that the nurse aide (NA 2) stood while feeding Resident 59, Resident 77, and Resident 81. There was no attempt by NA 2 during this timeframe to sit with an individual resident and assist them to complete their meals with dignity. CFR 483.10(a)(1)(2)(b)(1)(2) Resident rights/Exercise of rights Previously cited 3/22/19

Based on clinical record review and incident report documentation, it was determined that the facility failed to adequately supervise one resident to prevent elopement from the secured health center without staff's knowledge for one of four sampled residents who were at risk for elopement. (Resident R1) Findings include: Clinical record review revealed that Resident R1 had [DIAGNOSES REDACTED]. Review of an elopement risk assessment form dated October 12, 2015, revealed that the resident was at risk for elopement. The assessment indicated that the resident was disoriented, ambulated with a rolling walker, expressed the desire to go home on occasion, had a history of [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had cognitive impairment, required supervision for transfers and ambulation, and had a history of [REDACTED]. Review of a facility submitted report revealed that on January 3, 2016, at 8:00 p.m., the resident had been found outside of the secured health center when a nurse aide who had been in her car in the parking lot heard the resident yell and found him sitting on the ground approximately 50 feet from the entrance to the health center. The resident was transferred and admitted to the hospital at this time. Review of the hospital records revealed that the resident was diagnosed with [REDACTED]. Further review of facilty documentation revealed that on January 3, 2016, Resident R1 had ambulated to the lobby by the front door at 7:30 p.m., and was looking for his car. A nurse assisted the resident back to the sunroom on A wing and placed his oxygen on. Review of the receptionist's statement revealed that the resident had returned back to the lobby and was sitting on the couch. At approximately 8:00 p.m., the receptionist left the lobby area and he was still sitting on the couch at that time; however, when she returned the receptionist indicated that the resident was no longer sitting on the couch. The facility failed to have documented evidence of attempting or evaluating the need for increased supervision to Resident R1 in light of his recent exit seeking behavior and identified risk for elopement and as a result, the resident exited the facility without staff's knowledge and sustained a fractured hip. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 3/13/15