Every finding on record at Little Flower Manor

Based on review of policy, review of facility provided documentation and interview with staff, it was determined that facility did not ensure to notify state long-term care ombudsman of facility-initiated transfers and discharges for six of six months reviewed (June 2025 through November 2025)Review of facility policy 'Admission, Discharge, and Transfer,' reviewed in October 2025, indicates that a list of discharges and transfers will be sent to the Long-Term Care Ombudsman monthly.Review of facility provided discharge and transfer notifications for month of June 2025 indicated that a total of 20 discharges were sent to county ombudsman.Further review of facility provided discharge and transfer notifications for month of July 2025 indicated that a total of 22 discharges were sent to county ombudsman.Further review of facility provided discharge and transfer notifications for month of August 2025 indicated that a total of 28 discharges were sent to county ombudsman.Further review of facility provided discharge and transfer notifications for month of September 2025 indicated that a total of 26 discharges were sent to county ombudsman.Further review of facility provided discharge and transfer notifications for month of October 2025 indicated that a total of 32 discharges were sent to county ombudsman.Further review of facility provided discharge and transfer notifications for month of November 2025 indicated that a total of 35 discharges were sent to county ombudsman.Interview with Nursing Home Administrator, Employee E1 on December 11, 2025, at 11:00 AM revealed that the facility was not providing notification of facility-initiated transfer and discharges to the State Ombudsman as require. The facility was only providing notification to the County Ombudsman program. 28 Pa Code 201.14(a)Responsibility of licensee28 Pa Code 201.18(b)(2) Management

Based on review of clinical records and staff interview, it was determined that the facility failed to ensure that a resident's drug regimen was free of unnecessary drugs for one of 18 residents reviewed (Resident R30). Findings included: Review of facility policy tilted Medication Regiment Review, revised June 2024, revealed if an irregularity is not time-sensitive but should be addressed before the consultant pharmacists' next monthly MRR, the facility staff and the consultant pharmacist will confer on the timeliness of attending physician/prescriber responses to identified irregularities based on the specific resident's clinical condition. Further review of facility policy revealed the physician/ prescriber should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident per policy, or applicable state and federal regulations. Clinical record review revealed Resident R30 was admitted to the facility on [DATE] with a diagnosis that included Anxiety, Hypertension (high blood pressure), and acute respiratory failure. Review of Resident R30's monthly pharmacy review dated October 29, 2024 revealed Resident R30 received a nonsedating antihistamine, Loratadine 10 milligrams (mg) daily for seasonal allergic rhinitis. Pharmacist comments revealed administration should be limited to the allergy season to avoid adverse events attributed to daily long-term use. Pharmacist recommended physician to reevaluate the continued need for Loratadine perhaps a trail discontinuation/PRN (as needed) period. Further review of Resident R30's monthly pharmacy review revealed the physician agreed and accepted the recommendation on October 31, 2024. Review of Resident R30's clinical record revealed Resident R30 had a standing order for Loratadine 10 mg started on February 13, 2024. The order continued to be a standing order and did not have a stop date that was recommended by pharmacist on October 29, 2024. Interview conducted on January 08, 2024 with Employee E2, Director of Nursing, confirmed Resident R30 continued to have a standing order for Loratadine 10 mg and should have been discontinued per pharmacy recommendation and physician response. 28 Pa. Code 211.2 (d)(3) Medical Director 28 Pa. Code 211.9 (k) Pharmacy Services

Based on review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to develop a person-centered comprehensive care plan for one of 18 residents reviewed (Resident R70). Findings include: A review of the facility policy Care Plan, revised May 2023, revealed the facility will develop and implement a comprehensive person-centered care plan for each resident. The care plan will include measurable objectives and time frames to meet a resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment. The care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Clinical record review revealed Resident R70 was admitted to the facility on [DATE], with diagnoses of Rhabdomyolysis (serious condition where your muscles break down and release toxins into your blood and kidneys), Hypertension (high blood pressure), and Malignant neoplasm of prostate (prostate cancer). Review of Resident R70's nursing notes from October 1, 2024 to January 8, 2024 revealed Resident R70 has been refusing various treatments several times weekly, such as Activities of Daily Living, medication, physical therapy, and occupational therapy. Review of Resident R70's care plan revealed no care plan related to Resident R70's refusal to treatments. Interview conducted on January 09, 2025 at 9:40 a.m. with Licensed nurse, Employee E3, confirmed Resident R70 did not have a care plan in place relating to the resident refusals to treatments. 28 Pa. Code: 211.12 (d) (1) (5) Nursing services. 28 Pa. Code 211.10 (c) Resident care policies.

Based on review of facility policy, observations, and staff interview it was determined that the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings Include: Review of facility policy revealed products transferred from the manufacturers ' original packaging or opened must be stored and labelled in accordance with the manufacturers after opening instructions. Perishable foods must have limited shelf life and must be refrigerated. This is normally 72 hours for in-unit produced foods. An initial tour of the Food Service Department was conducted on March 8, 2024, at 9:30 a.m. with Employee E4, Assistant Food Service Director. Observations of the reach in refrigerator revealed the following food items stored in facility containers: pureed red velvet cake dated 2/26, cranberry sauce dated 2/19, and multiple bowls of apple sauce with no dates. Observations in the dish area revealed dietary staff preparing to clean meal trays from breakfast. Interview with Employee E4, Assistant Food Service Director, revealed the dish machine used was a high temperature dish machine (sanitizes dishes using extremely hot water during their rinse cycle to remove pathogens. The water is heated to at least 180 degrees Fahrenheit). Observations of the dish machine revealed the wash temperature was reaching 135 degrees Fahrenheit and the final rinse temperature was reaching 120 degrees Fahrenheit. Interview with Employee E4, Assistant Food Service Director, confirmed these temperatures were not appropriate for proper sanitation of the dishes. 28 PA Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility did not complete a comprehensive care plan for four of eighteen residents reviewed. (Residents R1, R11, R12, R24) Findings include: Interview held with Nursing Home Administrator Employee E1 on March 11, 2024 at 1:00 p.m. The Nursing Home Administrator, Employee E1 revealed the facility was having an issue with accomdating staffing preferences for several females at the facility requesting male nurses aide. The facility stated that they are trying to accomodate preferences but have been unable to accomdate in some cases. When asked how many residents are preferring males caregivers the Nursing Home Administrator Employee E1 stated alot. Interview with Resident R1 on March 11, 2024 at 10:20 a.m. indicated that she prefers female nurse aide over male nurse aide, stating I don't feel as clean when hygiene care is provided by male nurse aide. Review of Resident R1's MDS Minimum Data Set revealed a BIMS Brief Interview for Mental Status of 14. Observations of R1 during morning medication administration on March 11, 2024 at 10:25 am, revealed R1 voicing her concern regarding male nurse aides to licensed nurse, Employee E3. E3 replied that she will bring resident's concern again to administration. Resident Council meeting was held on March 11, 2024 at 1:00 p.m. with eight awake, alert and oriented residents. During the resident council discussion the topic was brought up regarding male caregivers. Residents R11, R12, and R24 all stated that they prefer to have a female nurse aide give personal care such as bathing or toileting but sometimes are given a male nurses aid. The group discussed how this was brought up to the Nursing Home Administrator Employee E1 during previous Resident Council meetings and and Nursing Home Administrator reiterated that this is what it is and we need to get more comfortable with having males as aides because that is who is applying and qualified. Review of R1, R11, R12 and R24's care plan show no description of the resident's preferring a female caregiver over a male caregiver. Review of Resident Council Meeting Minutes from February 2024 described having males as aides as being a concerned discussed. 28 Pa Code 211.10( c)(d) Resident care policies 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services

Based on observation, interview with staff and review of facility policy, it was determined that the facility did not ensure that controlled substances were stored is a safe and secure compartment for two of two medication rooms. (Unit A and Unit B) Findings include: Observation of the Medication Room in Unit B conducted on May 11, 2023, at 10:08 a.m. with unit manager Employee E7 revealed that the refrigerator where the controlled substances were stored did not have a lock. Further observation revealed a hand carry narcotics box with a lock but was not permanently affixed to the refrigerator. Observation of the narcotic box revealed one opened vial of Lorazepam 2mg/ml, a controlled substance designated as schedule IV control substance (schedule IV having the low potential for abuse relative to schedule II which has the highest potential for abuse) was inside the narcotic box. Interview with Licensed nurse,Employee E7 conducted at the time of the observation confirmed that the narcotic box was not permanently affixed to the refrigerator. Observation of the Medication Room in Unit A conducted on May 11, 2023, at 10:14 a.m. with Unit Manager Employee E9 revealed that the refrigerator where the controlled substances were stored did not have a lock. Further observation revealed a hand carry narcotics box with a lock but was not permanently affixed to the refrigerator. Interview with Unit Manager, Employee E9 conducted at the time of the observation confirmed that the narcotic box was not permanently affixed to the refrigerator. Interview with Director of Nursing and Director of Quality Improvement Employee E3 conducted on May 11, 2023, at 10:30 a.m. revealed that he will have engineering affix the box permanently to the refrigerator. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on observation, review of facility policy, interviews with residents and staff and review of facility documentation, it was determined that the facility failed to ensure residents had access to grievance/concern forms for two of two nursing units observed. (Unit A and Unit B) Findings include: Review of policy title Grievances dated March 16, 2023 states Little Flower Manor will inform residents orally and in writing of their right to make complaints or Grievances and the process to do so during admission. The notice shall include: a. Resident's right to file a grievance orally and in writing. b. Resident's right to file a grievance /concern anonymously. During a resident council meeting held on May 10, 2023 at 11:00 a.m. with Residents: R77, R12, R27, R22, R18, R36, R28, it was stated that all seven residents were unaware of where to find a grievance/concern form. Review of the facility grievance log from January 1, 2023 till May 9, 2023 revealed only one grievance submitted on April 3, 2023. Observations of Unit A and Unit B with the Social Services Director, Employee E4 on May 10, 2023 at 9:45a.m. revealed that none of the nursing units have grievance/concerns forms readily available for residents, family, or visitors to be completed and submitted anonymously if desire. Interview with the Nursing Home Administrator (NHA) on May 10, 2023 at 10:10 a.m. revealed that no grievance forms were available. NHA stated, issues usually come up at care conference meetings and are addressed then. We do not have grievance forms available readily. 28 Pa. Code 201.18(e)(4) Management

Based on a review of facility documents, observations, and interviews with staff, it was determined that the facility did not establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for one of two nursing units (Unit A). Findings include: Review of the Shift-to-shift Narcotic Accountability record review conducted on May 11, 2023 at 9:08 a.m. with Licensed nurse, Employee E11 on Unit A revealed that the shift to shift narcotic accountability sheets and individual narcotic count sheets were in a binder. Further, review of the shift to shift narcotic accountabilityv revealed that the shift to shift narcotic accountability only accounted for the controlled substances present at the time of the count but did not account for the individual resident-controlled substance record/receipt/log for each controlled substance medication prescribed for a resident dispensed by the pharmacy and stored in the narcotic boxes. Interview with Licensed nurse, Employee 11 conducted at the time of the observation revealed that the in-coming and out-going licensed nurses were signing for the controlled substances present in the narcotic box and their corresponding narcotic count sheets in the narcotic binder at the time of the count. Further, Employee 11 confirmed that if an entire blister pack of controlled substance and its corresponding Narcotic count sheet was missing, there was no system in place to account for that missing set of controlled substance. Interview with Director of Nursing, and Director of Quality, Improvement, Employee E3 conducted on May 11, 2023, at 11:06 a.m. confirmed that the facility did not have a system in place to account for the individual narcotic in the narcotic bins and that there was no tracking system to account for a set of missing controlled substance and its corresponding narcotic count sheet. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to follow appropriate infection control practices related to medication administration for one of three residents (Resident R28) and wound care for one of one resident observed (Resident R54) Findings include: Wound care observation on Resident R54 conducted on May 10, 2023, at 10:10 a.m. with Licensed nurses, Employee E10 and Employee E8 revealed that Employee E10 with gloved hands and touch Resident R54's dressing and proceeded to turn off the overhead light by puling at the cord using the gloved hand that touched the resident's dressing. Further observation revealed that Licensed nurse, Employee E10 proceeded to continue with the treatment without changing her gloves or washing or sanitizing her hands. Interview with Licensed nurse, Employee E10 after the treatment confirmed that she touched the cord with the same gloved hand she used to touch Resident R54's dressing; that she did not wash or sanitize hands and that she did not change gloves before resuming the treatment procedure for Resident R54. Medication pass observation in Unit A conducted on May 11, 2023, at 8:14 a.m. with Licensed nurse, Employee E11 revealed that while preparing the medications for Resident R28, Employee E11 dropped an empty blister pack on the floor, picked it up, did not wash hands, continued prepping the medications and gave the medications to resident without washing hands on using the hand sanitizer. Interview with Licensed nurse, Employee E11 conducted at the time of the observation confirmed that she dropped an empty blister pack on the floor, picked it up, did not wash hands, continued prepping the medications and gave the medications to resident without washing hands on using the hand sanitizer. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation, clinical record review and interview with staff and residents, it was determined that the facility did not ensure that the resident's wishes for an advance directive (a document which states one's wishes for life-sustaining medical or surgical treatment), were reflected accurately in the clinical record for one of 18 records reviewed (Resident R183). Findings include: Review of facility policy titled Little Flower Manor Advance Directive Policies and Procedures dated July 14, 2022, revealed that it is the policy of the facility that If the resident has a pre-existing advance directive, he or she must provide a validly executed advance directive so that it can be reviewed and made a part of his or her medical record. The policy further states that The executed advance directive must be placed in the resident's medical record as soon as possible. Review of clinical documentation for R183 revealed that the resident was admitted to the facility on [DATE]. An advance directive was noted to have been uploaded to the resident's electronic medical record. Review of this advance directive revealed that it was not the resident's advance directive, but his wife's, which stated that in the event of an end-of-life situation, I do not want aggressive medical care, I do not want tube feedings to be given, and My agent must follow these instructions. No other documentation was noted of the resident's code status or wishes for an end-of-life situation. Interview with employees E1 and E2 on July 15, 2022, at 11:00 AM revealed that no code status order or POLST (Pennsylvania Order for Life Sustaining Treatment, a document which allows a resident to express their wishes for an end-of-life situation) existed for R183 and that the advance directive on file for him was not his. In a follow-up interview with E1 and E2 at 11:19 AM they stated that they spoke with R183, and that he desired to be full code (every intervention is to be used to restore or maintain life in an end-of-life situation). Interview with employees E4 and E5 on July 15, 2022, at 11:26 AM, revealed that when the admissions department had uploaded R183's advance directive, they did not properly verify that it was the correct document. 28 Pa. Code 201.29(i) Resident rights 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(a)(c) Resident care policies 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of clinical records, review of facility documentation and interviews with staff, it was determined that the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in actual harm to Resident R1 who received the incorrect volume of the enteral formula, developed vomiting, required transfer to the hospital and was diagnosed with acute respiratory failure secondary to aspiration, for one of four residents reviewed on enteral feeding. (Resident R1). This deficiency was identified as Immediate Jeopardy past non-compliance. Findings include: Review of facility policy, Gastrostomy Tube Feeding dated last revised March 2022, revealed that, All residents fed by tube shall receive appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and to restore, if possible, normal feeding functions. Continued review revealed that the facility will provide tube feedings as ordered by the physician. Review of Resident R1's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) assessment, dated January 4, 2022, revealed that the resident was admitted to the facility November 9, 2018, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the MDS assessment revealed that Resident R1 received 51% or more of her daily nutrition through a feeding tube. Review of Resident R1's progress notes revealed a Tube Feeding Note, dated March 7, 2022, at 1:36 a.m. which indicated that the resident received a tube feeding formula of Nepro 1.8 infused at 35 ml/hr. (milliliters/ per hour) and that the resident tolerated her tube feeding without difficulty. Review of nursing documentation dated March 7, 2022, at 10:32 p.m. indicated that the resident had a copious [abundant] cough that was not present earlier in shift. Assessed resident with coarse rhonchi [abnormal lung sounds] throughout. Review of facility documentation submitted to the Department of Health on March 8, 2022, revealed that on March 7, 2022, at 9:49 p.m. Resident R1 developed symptoms of cough and congestion. When the nursing supervisor went to assess Resident R1, she discovered that the rate on the feeding pump was at 280 ml/hr. The tube feeding was immediately stopped and 30 minutes later the resident began vomiting. Resident R1 was subsequently transferred to the local hospital. Review of Medication Administration Records (MAR) for March 2022, revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Total nutrient volume 700 ml over 24 hours. Downtime 8:00 a.m. to 12:00 p.m. Hang 35 ml from 7:00 a.m. to 8:00 a.m. Hang 105 ml from 12:00 p.m. to 3:00 p.m. Hang 280 ml from 3:00 p.m. to 11:00 p.m. Hang 280 ml from 11:00 p.m. to 7:00 a.m. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility investigation documentation related to the event that occurred on March 7, 2022, confirmed that Employee E9, Licensed Practical Nurse (LPN), went into Resident R1's room at 6:15 p.m. to hang a new bottle of enteral formula. At 9:49 p.m. Resident R1 developed cough and congestion. The nursing supervisor went into the room and discovered that the feeding pump had a rate set at 280 ml/hr. The prescribed rate was 35 ml/hr, Resident R1 began vomiting and was transferred to the hospital. Continued review of facility documentation revealed that documentation obtained from the feeding pump machine revealed that Resident R1 received 980 ml of enteral feeding over 3.5 hours. Resident R1 received her enteral feeding at the incorrect rate of 280 ml/hr for 3.5 hours before the nurse became aware of the error. Review of hospital documentation, dated March 10, 2022, revealed that Resident R1 presented in the emergency room from the facility with respiratory distress just prior to arrival with oxygen saturations of 50 percent on room air (normal oxygen saturations are 90-100 percent on room air) per EMS (Emergency Medical Services). Resident R1 was admitted to the hospital for acute hypoxic respiratory failure (not able to exchange oxygen properly in the lungs) secondary to aspiration. Resident R1 was placed on antibiotic therapy for aspiration pneumonia (occurs when food, saliva, liquids or vomit is breathed into the lungs) as well as nebulizer bronchodilators (medications that make breathing easier by relaxing muscles in the lungs and widening the airways) and steroids (medications used to reduce swelling) for wheezing (abnormal lung sounds). Review of Licensed nurse, Employee E9's personnel record revealed that Employee E9 was a newly hired nurse who completed orientation on February 9, 2022. Employee E9 was signed off as competent for the administration of feeding tubes on March 1, 2022. During an interview on March 24, 2022, at 10:26 a.m. licensed nurse, Employee E9, confirmed that she made an error when hanging a new bottle of tube feeding formula for Resident R1. Employee E9 stated that she had received direct and multiple trainings from nursing staff regarding how to administer, assess and care for a tube feeding, including hanging a new bottle and programming the pump. Employee E9 stated that she felt that her training was adequate and that she felt comfortable with administration of tube feedings. Interview on March 24, 2022, at 9:40 a.m. Registered Nurse, Supervisor Employee E10, RN confirmed that Licensed nurse, Employee E9, reported to her that Resident R1 developed a cough. Employee E10 stated that when she went to assess Resident R1, she discovered that the feeding pump was infusing at 280 ml/hr. Employee E10 stated that at that time Resident R1 was coughing and wheezing. Employee E10 immediately turned off the feeding pump and notified the on-call physician. Employee E10 stated that when she went back to assess the resident again, Resident R1 appeared to be aspirating, had what appeared to be tube feeding formula coming out of her mouth and had labored breathing. Employee E10 applied oxygen to Resident R1 and transferred her to the local hospital via Emergency Medical Services. Interview conducted on March 21, 2022, at 9:15 a.m. with the Nursing Home Administrator confirmed that Licensed nurse, Employee E9, incorrectly administered Resident R1's tube feeding which resulted in Resident R1 being admitted to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] This deficiency was identified as Immediate Jeopardy past non-compliance. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator, on March 24, 2022 at 2:38 pm. On March 7, 2022, the facility initiated a plan of correction to address the failure of not following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility plan of correction included the following: 1. All residents who had tube feedings were checked to ensure the proper rate was being administered. Completed March 7, 2022. 2. Resident R1 was transferred to the hospital via Emergency Medical Services for evaluation for aspiration. Facility provided all pertinent information to hospital and family was notified March 7, 2022. 3. An investigation was initiated. Licensed nurse, Employee E9 was placed on a performance improvement plan. The feeding pump was evaluated for proper function and infusion history data was obtained. Completed March 8, 2022. 4. Facility policy regarding tube feeding was reviewed and revised. Completed March 9, 2022. 5. Daily notes are completed for all residents who receive tube feedings verifying the rate, formula, tolerance and resident condition. 6. An audit tool was developed and will be completed by the evening shift supervisor for further oversight. Audits will be completed daily for 30 days, then three times per week for 30 days, then weekly for 30 days. 7. The curriculum for all new hires was expanded to include review of Tube Feeding Administration/Assessment of the Resident on Tube Feeding and Caring for the Tube Feeding. The oversight of this will be performed by the Nurse Educator and the Human Resource Director prior to the employee's first orientation day with their nurse preceptor. Completed March 11, 2022. 8. All new nursing hires underwent a review of the correct operation of the enteral feeding pumps and the need to verify the rates with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Completed March 9, 2022. 9. Facility Education Program was updated to include more in depth education regarding enteral feedings/caring for a feeding tube and the assessment of individuals receiving enteral feedings. 10. The Director of Quality and Safety and the DON have developed Nursing Competency Examinations and all nursing professional staff have completed this examination and the involved individual and new hires will be subject to these exams to determine their level of competency/need for further education in areas of medical terminology, medications, etc. 11. An Apparent Cause Analysis was completed March 14, 2022. 12. The Quality Improvement Committee have discussed the incorporation of the information on the audit tool to have any pertinent information included into the Tube Feeding Progress Note in the Electronic Medical Record System to allow for greater oversight. The Quality Improvement Committee will continue to review nurse education and audits and provide feedback as needed. The facility alleged compliance with their plan of correction as of March 14, 2022. Review of facility documentation revealed that the corrective plan was immediately developed and initiated on March 7, 2022. Audits were initiated to ensure that all tube feedings were infusing at prescribed rates. All residents who receive tube feedings had daily written assessments that included verification of tube feeding: route, formula, rate, volume, flushes, residual, tolerance, symptom assessment and hydration assessment. An audit tool was developed and completed by nursing supervisors and included verifications of tube feeding cleanliness, head of bed elevated, tube feeding site, feeding container label, verification of bottle and pump with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility reviewed and updated their policy related to tube feedings. Additionally, the facility expanded its training modules related to tube feedings and re-inserviced nursing staff along with skill competency reviews. Education modules, knowledge testing and skills competency reviews were completed with nursing staff. Interviews were conducted with licensed nursing staff regarding trainings and competencies related to tube feeding care, assessments and administration. All nurses reported that they felt comfortable with tube feeds and that they received sufficient trainings from the facility. Nurses verbally demonstrated knowledge of current tube feeding practices. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.10(c) Resident Care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation, clinical record review and interview with staff, it was determined that the facility did not ensure that physician orders [REDACTED]. (Resident R93 and R54). Findings include: Observation of medication administration on May 20, 2011, at 8:55 a.m., revealed Employee E1, a licensed nurse, administering morning medications to Resident R93. Further observation of medication pass revealed that Employee E1 checked Resident R93's blood pressure which was noted to be 102/74. Employee E1 then administered [MEDICATION NAME] (antihypertensive medication) 50 mgs.(milligrams) to Resident R93. Review of the clinical record for Resident R93 revealed a physician order [REDACTED]. Interview with Employee E1, on May 20, 2011, at 9:20 a.m., confirmed that Resident R93's systolic blood pressure reading was below the physician ordered parameters and should not have been administered to the resident. Review of Resident R54's clinical record revealed that the resident had been admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Further review of the clinical record revealed a physician order [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the MAR indicated [REDACTED]. Interview with Employee E2, registered nurse, confirmed that Resident R54 had not received the [MEDICATION NAME] antihypertensive medication as ordered on May 19, 20 and 21, 2011. Previously cited 6/29/2010. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services. 28 Pa. Code: 211.9 (d) Pharmacy services.