Every finding on record at Luther Crest Nursing Facility

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessments were completed to accurately reflect the resident's current status for one of 13 sampled residents. (Resident 2) Findings include: Clinical record review revealed that Resident 2 had diagnoses that included diabetes mellitus, muscle weakness, need for assistance with personal care, and major depressive disorder. A physician's orders dated April 21, 2024, July 22, 2024, and March 28, 2025, directed staff to apply and monitor an electronic monitoring device to the resident's arm. Review of the MDS assessments dated July 13, 2024, October 13, 2024, and January 13, 2025, section P indicated the resident did not use the electronic monitoring device. The MDS inaccurately reflected the use of an electronic monitoring device. In an interview on June 5, 2025, at 10:12 a.m., the Director of Nursing confirmed that Resident 2's MDS assessments were inaccurate and did not reflect the resident's current status.

Based on clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for two of 13 sampled residents. (Resident 29, 36) Findings include: Clinical record review revealed that Resident 29 had diagnoses that included congestive heart failure, coronary artery disease, and hypertension. A physician's order dated May 23, 2025, directed staff to weigh the resident daily. A review of the Medication Administration Record (MAR) for May and June 2025, and Treatment Administration Record (TAR) for May and June 2025, revealed that there was no evidence that staff weighed Resident 29 as ordered on May 25 and 26, 2025, and June 1 and 2, 2025. Clinical record review revealed that Resident 36 had diagnoses that included dementia, protein-calorie malnutrition, and chronic kidney disease. A physician's order dated April 29, 2025, directed staff to weigh the resident weekly. A review of the MAR and TAR for May 2025, revealed that there was no evidence that staff weighed Resident 36 as ordered between May 2 and May 27, 2025. In an interview on June 5, 2025, at 9:49 a.m. and 1:03 p.m., the Director of Nursing confirmed that there was no documented evidence that staff attempted to weigh the residents as ordered. 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 provide services to improve and/or maintain activities of daily living that included ambulation for three of 14 sampled residents. (Residents 2, 7, 40) Findings include: Clinical record review revealed that Resident 2 had diagnoses that included a history of fractured ribs, vascular dementia, and muscle weakness. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and oriented and required supervision/touching assistance with ambulation. Review of the restorative program plan of care that was recommended by physical therapy on January 5, 2024, indicated that the recommendation was for a restorative ambulation program to be implemented by staff. The goal was for the resident to maintain the current level of mobility of walking 200 feet, two times a day with a roller walker and assistance of one person. A review of the current care plan revealed that the resident was on a restorative nursing program for ambulation. The intervention was for the resident to ambulate 200 plus feet with a walker and assist of one two times a day. Review of nursing documentation for the last 30 days revealed that there was a total of six times that the resident was only offered assistance with walking one time a day. In addition, there was a total of five days that there was no documented evidence that the staff had assisted the resident at all with the restorative ambulation program. Clinical record review revealed that Resident 7 had diagnoses that included polyosteoarthritis, age related physical disability and difficulty walking. The MDS assessment dated [DATE], indicated that the resident was alert and used a walker for ambulation. On May 30, 2024, a physician documented that the resident was alert and communicative. Review of a physical therapy discharge summary dated March 11, 2024, indicated that the resident had met the goal of walking 50 feet with a walker, with supervision and stand by assistance for safety. The summary further indicated that the resident had reached maximum potential and the recommendation was for staff to provide a restorative program for ambulation. Review of the current restorative plan of care that had been initiated by physical therapy revealed that the resident was to ambulate 20 to 50 feet one to two times a day with a roller walker and assist of one with a gait belt. Review of nursing documentation for the last 30 days revealed that there was a total of 14 times that the resident was only offered assistance with walking one time a day. In addition, there was a total of three days that there was no documented evidence that the staff had not assisted the resident at all with the restorative ambulation program. In an interview on July 10, 2024, at 10:16 a.m., the resident stated that she does like to walk, but that she was not offered assistance to walk daily on a consistent basis. Clinical record review revealed that Resident 40 had diagnoses that included Alzheimer's disease, dementia, and high blood pressure. The MDS assessment dated [DATE], indicated that the resident had confusion, but could usually communicate with and understand others. Review of a physical therapy discharge summary dated June 10, 2024, indicated that the resident had met the goal of walking 75 feet with a walker, with a minimum of one assistance for safety. The summary further indicated that the resident had reached maximum potential and the recommendation was for staff to provide a restorative program for ambulation. Review of the current restorative plan of care that had been initiated by physical therapy revealed that the resident was to ambulate 50 to 100 feet daily with a roller walker and assist of one with a gait belt and a wheelchair to follow. Review of nursing documentation for the last 30 days revealed that there was a total of 15 days that there was no documented evidence that staff had assisted the resident at all with the restorative ambulation program. In an interview on July 11, 2024, at 9:30 a.m., the Director of Nursing stated that there was no documented evidence that the restorative ambulation programs had been consistently offered to the aforementioned residents as recommended by physical therapy. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide treatment in accordance with physician's orders for one of three sampled residents with pressure ulcers. (Resident 19) Findings include: Clinical record review revealed that Resident 19 had diagnoses that included heart failure and muscle weakness. The Minimum Data Set assessment dated [DATE], indicated that the resident required assistance from staff for personal hygiene. Review of the care plan revealed that there was a risk for skin impairment related to the resident's fragile skin, decreased mobility, and incontinence. Review of a nursing note dated May 31, 2024, indicated that the resident had a new pressure related wound on the buttocks. On July 5, 2024, a physician ordered for staff to cleanse and provide a treatment to the wound twice a day on the day and evening shift and as needed for dislodgement of the dressing. Observation on July 10, 2024, at 9:45 a.m., of a wound treatment for Resident 15 with the licensed practical nurse (LPN1) revealed that the dressing to be removed had a date of July 9, 2024, and the initials matched those of the LPN1. In an interview at the time of the observation, LPN1 confirmed that the old dressing was the one placed, dated, and initialed from dayshift on July 9, 2024, and that the previous evening's treatment was not completed as ordered. In an interview on July 11, 2024, at 10:23 a.m., the Director of Nursing confirmed that the wound care had not been completed on the evening shift of July 9, 2024, as per the physician order. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to notify the residents and the residents' representatives of transfers from the facility and reasons for the moves in writing for two of three sampled residents who were transferred to the hospital. (Residents 2, 39) Findings include: Review of the facility policy entitled, Bed-Holds and Returns, last reviewed January 25, 2024, revealed that prior to transfers the residents and resident representatives were to be informed in writing of the details of the transfer per the Notice of Transfer. Clinical record review revealed that Resident 2 was transferred and admitted to the hospital on March 29, 2024, after a change in condition. Clinical record review revealed that Resident 39 was transferred and admitted to the hospital on February 23, and April 17, 2024, after a change in condition. In an interview on July 11, 2024, at 9:30 a.m., the Administrator stated that there was no documented evidence that the residents or the residents' representatives were given the information in writing of the details of the transfer as per the facility policy.

Based on observation and staff interview, it was determined that the facility failed to post accurate daily nurse staffing information. Findings include: Observation on July 9, 2024, at 8:30 a.m., 10:30 a.m., and 11:00 a.m., revealed that the posted nurse staffing information was from the day before, July 8, 2024. In an interview on July 11, 2024, at 9:30 a.m., the Director of Nursing stated that on the morning of July 9, 2024, the nurse staffing information had not been posted for the correct date. 28 Pa. Code 201.18(b)(3) Management.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy (an agreement for the facility to hold a bed for an agreed rate during a hospitalization ) to the resident, family member, or legal representative at the time of the transfer out of the facility for two of three sampled residents who were transferred to the hospital. (Residents 2, 39) Findings include: Review of the facility's policy entitled, Bed-Holds and Returns, last reviewed January 25, 2024, revealed that prior to transfers, residents or resident representatives were to be informed in writing of the bed-hold and return policy. Clinical record review revealed that Resident 2 was transferred and admitted to the hospital on March 29, 2024, after a change in condition. Clinical record review revealed that Resident 39 was transferred and admitted to the hospital on February 23, 2024, and April 17, 2024. In an interview on July 11, 2024, at 9:30 a.m., the Administrator stated that there was no documented evidence that the residents or the residents' representatives were given information regarding bed-holds after their transfers out to the hospital as per facility policy.

Based on clinical record review and staff interview, it was determined that the facility failed to maintain clinical records that were accurate for three of 16 sampled residents. (Resident 25, 37, 109) Findings include: Clinical record review revealed that Resident 25 was admitted to the facility on [DATE], with diagnoses that included osteoporosis and fracture of the lumbar vertebra. On June 1, 2023, the physician ordered for staff to administer narcotic pain medication (oxycodone) every four as hours as needed for severe pain. Review of the current care plan indicated that Resident 25 had pain related to her fracture and that staff was to utilized non medication interventions and administer as needed pain medication if non medication interventions were ineffective. Review of the Medication Administration Record (MAR) for June 1 through 21, 2023, revealed that Resident 25 received the as needed narcotic pain medication on 18 occasions. There was no documented evidence that staff offered non medication interventions prior to the administration of the as needed pain medication. Clinical record review revealed that Resident 37 had diagnoses that included osteoarthritis and hemiplegia and hemiparesis following cerebral infarction (weakness or the inability to move on one side of the body following a stroke). On May 6, 2023, the physician ordered for staff to administer narcotic pain medication (oxycodone) every eight as hours as needed for severe pain. Review of the MAR for June 1 through 21, 2023, revealed that Resident 37 received the as needed narcotic pain medication on five occasions. There was no documented evidence that staff offered non medication interventions prior to the administration of the as needed pain medication. Clinical record review revealed that Resident 109 was admitted to the facility on [DATE], with diagnoses that included osteoporosis. On June 14, 2023, the physician ordered for staff to administer narcotic pain medication (oxycodone) every four hours as needed for moderate pain. Review of the MAR for June 14 through 21, 2023, revealed that Resident 109 received the as needed narcotic pain medication on six occasions. There was no documented evidence that staff offered non medication interventions on five occasions prior to the administration of the as needed pain medication. In an interview on June 22, 2023, at 11:57 a.m., the Director of Nursing confirmed that staff offered but did not document non medication interventions prior to the administration of narcotic pain medication. 28 PA. Code 211.5(f) Clinical records.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure pain management was consistent with professional standards and failed to attempt non-pharmacological interventions to alleviate pain prior to or in conjunction with the administration of pain medication prescribed on an as needed basis for two of 15 sampled residents. (Residents 22, 48) Findings include: Clinical record review revealed that Resident 22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident experienced occasional mild pain. Narcotic pain medication ([MEDICATION(S)]) was ordered by the physican on March 23, 2022, for 50 milligrams (mg) every six hours as needed for pain. The resident also had a physician's order dated February 9, 2020, for a non-narcotic analgesic (acetaminophen) 650 milligrams every four hours as needed for pain. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . She did not receive the as needed non-narcotic pain medication in April or May 2022. The physician's orders did not include parameters for the level of pain to direct administration of the as needed pain medications. In addition, there was a lack of documentation to indicate the resident's level of pain when she received the as needed pain medication. Also, there was no evidence that non-pharmacological interventions were offered when the as needed pain medication was administered. Clinical record review revealed that Resident 48 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE], indicated that the resident frequently experienced pain at a level of six (scale 0 - 10). It was noted that she had received as needed pain medication and had not received non-medication pain interventions in the seven day assessment period. Narcotic pain medication ([MEDICATION(S)]) was ordered by the physican on April 6, 2022, for 5 mg every four hours as needed for pain rated 7 - 10 and 2.5 mg every four hours as needed for pain 4-6. The resident also had a physician's order dated February 11, 2022, for a non-narcotic analgesic (acetaminophen) 650 mg every four hours as needed for pain. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She did not receive the as needed non-narcotic pain medication in April or May 2022. There was a lack of documentation to indicate the resident's level of pain when she received the as needed pain medication. Also, there was no evidence that non-pharmacological interventions were offered when the as needed pain medication was administered. During an interview on June 6, 2022, the Regional Director of Nursing confirmed that physician's orders should include pain parameters for administration and level of pain should be recorded at the time of administration for as needed pain medications. In addition, documentation was not available to support that medications were administered in accordance with pain parameters and that non-pharmacological pain interventions were provided. 28 Pa. Code 211.9(a)(1) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based clinical record review and staff interview, it was determined that the facility failed to ensure that non-pharmacological behavioral interventions were provided prior to or in conjunction with the administration of [CONDITION(S)] medication prescribed on an as needed basis for one of 15 sampled residents. (Resident 22) Findings include: Clinical record review revealed that Resident 22 was had diagnoses that included dementia with behavioral disturbance, visual hallucinations, depression, adjustment [CONDITION(S)], and anxiety disorder. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident exhibited some depression and trouble falling asleep and no behavioral symptoms in the previous seven day assessment period. The resident was ordered by the physician to receive scheduled [CONDITION(S)] medications including an antipsychotic ([MEDICATION(S)] 100 milligrams (mg) at hour of sleep), an antidepressant ([MEDICATION(S)] 25 mg daily), and an antianxiety medication ([MEDICATION(S)] 7.5 mg three times per day). In addition, the resident had a physician's order dated March 3, 2022, for the antianxiety medication [MEDICATION(S)] 0.5 mg every six hours as needed for dementia with behavioral disturbance. Review of the medication administration record (MAR) revealed that Resident 22 received the as needed antianxiety medication 21 times in April 2022, (including four times in the MDS assessment period) and 10 times in May 2022. Resident 22's care plan included behavioral interventions to be used due to depression, hallucinations, and behaviors such as calling out, anxiety, and aggression. Interventions included removing the resident to a quiet place, reapproaching at a later time, speaking in a soothing voice, and offering a snack or activity. There was a lack of documentation to indicate that non-pharmacological behavioral interventions were provided or attempted prior to administration of the as needed psychoactive medication 13 of 21 times in April and six of 10 times in May. During an interview on June 3, 2022, at 10:00 a.m., the Regional Director of Nursing confirmed that non-pharmacological behavioral interventions should be documented on the MAR or nursing notes when an as needed psychoactive medication was administered. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, staff education documentation review, and staff interview, it was determined that the facililty failed to ensure that annual training for dementia management and resident abuse prevention and reporting was completed by six of nine sampled staff. (NA 1, NA 2, NA 3, NA 4, LPN 1, LPN 2) Findings include: The facility policy entitled, Abuse/Neglect/Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Such training shall include resident rights and appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. Review of employee education records revealed a lack of documentation to support that identified nurse aides (NA 1, NA 2, NA 3, and NA 4) and Licensed Practical Nurses (LPN 1 and LPN 2) had completed annual training for prevention and reporting of resident abuse. In addition, NA 2, NA 3, and NA 4 lacked evidence that annual training was completed for dementia management. During an interview on June 3, 2022, at 11:52 a.m., the Administrator confirmed that the identified nurse aides had been employed for over one year and had not completed the required training(s). During an interview on June 3, 2022, at 10:07 a.m., the Director of Nursing confirmed that LPN 1 and LPN 2 were agency nurses. Documentation provided by the agency indicated that LPN 1 last received abuse prevention and reporting training on February 25, 2020. Documentation was not provided for LPN 2. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.20(c) Staff development. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on facility policy review, staff education documentation review, and staff interview, it was determined that the facility failed to ensure staff completion of regular annual training, including no less than 12 hours of in-service education, for four of five sampled nurse aides. (NA 1, NA 2, NA 3, NA 4) Findings include: The facility policy entitled, Employee Training/Development, dated November 20, 2021, indicated that mandatory and voluntary continuing education opportunities were utilized on an ongoing basis to ensure that employees had sufficient training and information to competently perform job responsibilities and that mandatory trainings were required. Mandatory trainings included additional state required annual training. Review of facility employee education records revealed that there was no evidence that NA 1, NA 2, NA 3, and NA 4 completed at least 12 hours of in-service training. During an interview on June 3, 2022, at 11:52 a.m., the Administrator confirmed that NA 1, NA 2, NA 3, and NA 4 had not completed at least 12 hours of in-service training and had not completed mandatory trainings. She confirmed that all identified NAs had been employed for over one year, were current employees, and had worked during the previous year. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.20(c) Staff development. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined the facility failed to report an injury of unknown origin to the Administrator of the facility for one of 15 sampled residents. (Resident 10) Findings include: Review of the facility policy entitled, Abuse/Neglect/Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . In response, all incidents, including injuries of unknown origin, were to be immediately reported to supervisory nursing staff, who is responsible for promptly notifying the Administrator. In addition, allegations of abuse were to be reported to the physician. Clinical record review revealed that Resident 10 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], indicated that the resident required extensive staff assistance for activities of daily living such as transferring between surfaces, dressing, and personal hygiene. Review of nursing documentation dated May 13, 2022, revealed that the resident was found with a large discoloration to the left calf area and indicated, color appears darken. The physician noted on May 19, 2022, that the resident had an apparent hematoma of approximately duck egg size with coloration suggesting that it was at least a few days old. The physician indicated that the cause was unknown and that it was noted in facility records on May 13, 2022; but, that it was not brought to the provider's attention. In addition, there was no evidence to support that the injury of unknown origin was reported to the Administrator. During an interview on June 3, 2022, at 11:59 a.m., the Administrator confirmed she had not been notified of the Resident 10's injury of unknown origin that was identified on May 13, 2022. 201.14(c) Responsibility of licensee.

Based on policy review, clinical record review, observation and staff interview it was determined that the facility failed to ensure oxygen equipment was dated in accordance with facility policy for one of one sampled residents receiving oxygen therapy. (Resident 25) Findings include: Review of the facility policy entitled, Oxygen Therapy, dated November 2021, revealed staff were to label and date oxygen tubing. Clinical record review revealed that Resident 25 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 25 had a physician's order dated March 1, 2021, for continuous oxygen therapy at four liters via nasal cannula. Review of the treatment record for May 2022, revealed that the resident's respiratory equipment and tubing was to be changed, labeled and dated weekly. Observation on June 1, 2022, at 10:54 a.m., and again on June 2, 2022, at 9:30 a.m., revealed Resident 25 was in bed with a nasal cannula in place with dried encrusted nasal secretions. On June 1, 2022, at 10:54 a.m., and again on June 2, 2022, at 9:30 a.m., the resident's oxygen tubing was observed without a label and date. In an interview on June 3, 2022, at 9:55 a.m., the Regional Director of Nursing confirmed that the tubing should have been labeled and dated. 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 notify the residents and the residents' representative(s) of the transfers and the reasons for the moves in writing upon transfer from the facility for five of 15 sampled residents who were transferred to the hospital. (Residents 2, 6, 29, 41, 48) Findings include: Clinical record review revealed that Resident 2 was transferred and admitted to the hospital on May 23, 2022, after a change in condition. There was no documented evidence that the resident, the resident's responsible party and/or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 6 was transferred and admitted to the hospital on February 5, 2022, after a change in condition. There was no documented evidence that the resident, the resident's responsible party and/or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 29 was transferred and admitted to the hospital on April 12, 2022, after a change in condition. There was no documented evidence that the resident, the resident's responsible party and/or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 41 was transferred and admitted to the hospital on April 25, 2022, after a change in condition. There was no documented evidence that the resident, the resident's responsible party and/or legal representative was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 48 was transferred and admitted to the hospital on April 3, 2022, after a change in condition. There was no documented evidence that the resident, the resident's responsible party and/or legal representative was provided written information regarding the resident's transfer to the hospital. In an interview on June 3, 2022, at 11:47 a.m., the Administrator confirmed that written transfer notices were not given to the residents or the residents' representatives when the residents were transferred out of the facility.

Based on clinical record review, review of incident reports and staff interview, it was determined that the facility failed to ensure that assessed safety interventions were in place to prevent falls and failed to ensure that adequate supervision was provided in order to prevent falls for two of four sampled at risk for falls (Residents R1 and R4) Findings include: Clinical record review revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses that included a fractured arm status post a fall at home, need for assistance with personal care, and difficulty walking. Review of a fall risk evaluation dated December 14, 2021, indicated that the resident had a history of falls and was considered a high risk for falls. Review of the current care plan identified the resident was at risk for falls due to history of falls and decreased mobility with an intervention for slipper socks (gripper socks to help prevent falls). The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had some memory impairment, required extensive assistance from staff for most activities of daily living including bed mobility and transfers, and had a history of falls with a fracture. On January 30, 2022, a nurse noted that the resident had fallen and was found lying near the side of her bed in her room. The note further indicated that the resident had no socks or footwear on at the time of the fall. Review of the incident report revealed that the resident had been found laying between the beds in the room and was found on her left lateral side. The report indicated that the resident had no footwear on at the time of the fall. In an interview on February 3, 2022, at 12:30 p.m., the Director of Nursing stated that the resident was to have on slipper socks (gripper socks to help prevent falls) on at all times and that the socks were not in place at the time of the fall. Clinical record review revealed that Resident R3 had diagnoses that included Alzheimer's disease, abnormal gait, lack of coordination, a history of falling, and a need for assistance with personal care. Review of a fall risk evaluation dated October 7, 2021, indicated that the resident was disoriented, had one to two falls in the past month, was ambulatory and experienced falls attempting to go to the bathroom. The fall risk evaluation indicated that the resident was at a high risk for falls. The MDS assessment dated [DATE], indicated that the resident had some memory impairment, required assistance from staff for hygiene and bathing, was occasionally incontinent of urine and had a history of falls. Review of the care plan identified the resident at risk for falls due to a history of falls and non-compliance with safety measures. Review of nursing documentation indicated that on November 11, 2021, the resident was very restless during the evening shift. On November 23, 2021, a nurse noted that at 10:30 p.m., the resident was found on the floor sitting aside her bed by her wheelchair and that the fall was unwitnessed. On December 1, 2021, a nurse noted that at 11:15 p.m., the resident was heard yelling and was found on the floor with her head under the bedside table. On December 22, 2021, at 2:00 p.m., a nurse noted that the resident was again yelling for help and was found laying on her back next to the bathroom door, she had lost her balance and fell from her wheelchair. On December 29, 2021, at 11:24 p.m., a nurse noted that the resident was trying to get out of bed and she was found laying on the floor due to a fall on the left side of the bed. The resident had a laceration on her left forehead. Review of the incident report for January 29, 2022, revealed that at 8:05 p.m., the resident was observed sitting on her buttocks on the floor in front of her wheelchair. Review of nursing documentation and incident reports revealed that Resident R3 experienced five falls between November 23, 2021 and January 29, 2022, between the time frames of 2:00 p.m., and 11:30 p.m The facility failed to assess and provide adequate supervision for a resident who was at a high risk for falls and exhibited restless behaviors in order to prevent falls. 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 assess a resident's weight to ensure that the resident maintained acceptable parameters of nutritional status for one of three sampled residents who experienced weight loss. (Resident R1) Findings include: Review of the facility policy entitled, Weight Assessment and Intervention, dated August 2021, revealed that the multidisciplinary team was to monitor and intervene for undesirable weight loss for residents. Any weight change of five pounds, plus or minus for residents weighing greater then 100 pounds since the last weight assessment was to be re-taken within 24 hours for confirmation. Clinical record review revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current care plan identified the resident at nutritional risk related to pain and calorie protein malnutrition. Review of the weights revealed that on December 14, 2021, the resident weighed 142 pounds. On December 21, 2021, the resident weighed 130.4 pounds which was a weight loss of 11.6 pounds. On January 5, 2022, the resident weighed 124.8 pounds which was a weight loss of another 5.6 pounds. There was no documented evidence that the facility re-weighed the resident after a greater then five pound weight loss as per the facility policy. In an interview on February 3, 2022, at 2:00 p.m., the Director of Nursing stated that there was no documented evidence that the facility re-weighed the resident to confirm the weight loss on the aforementioned two occassions as per facility policy. 28 Pa. Code 211.10 (a) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, resident interview, and staff interview it was determined that the facility failed to ensure that a resident's call bell was answered in a timely manner for one of 14 sampled residents. (Resident 6) Findings include: Clinical record review revealed that Resident 6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment, dated May 24, 2021, revealed that Resident 6 was able to communicate needs, had no cognitive impairment, and required extensive assistance from staff with activities of daily living, including dressing and toilet use. Review of the current plan of care revealed that Resident 6 required an assist of one with roller walker and gait belt for transfers. There was an intervention for the call bell to be within reach. Observation of the call bell tracker monitor on August 25, 2021, at 09:50 a.m., revealed that Resident 6 had activated the bathroom call bell for assistance and staff did not respond as evidenced by the displayed time of over 25 minutes. In an interview on August 25, 2021, at 10:00 a.m., Resident 6 stated it takes long periods of time for staff to answer call bells and get assistance. During an interview on August 26, 2021, at 09:56 a.m., the Nursing Home Administrator and Assistant Director Of Nursing confirmed that call bells are expected to be answered within five to ten minutes. 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 for one of 14 sampled residents. (Resident 7) Findings include: Clinical record review revealed that Resident 7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE], revealed Resident 7 used an indwelling catheter (a tube inserted into the bladder) during the review period. Review of the care area assessment for urinary incontinence and indwelling catheter use revealed Resident 7 had an indwelling catheter and it would be addressed on the care plan. Review of Resident 7's clinical record revealed there was no care plan developed for the use of an indwelling catheter. In an interview on August 26, 2021, at 12:57 p.m., the Assistant Director of Nursing confirmed that there was no care plan developed for the use of an indwelling catheter. 28 Pa. Code 211.11(d) Resident care plan.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide a means of visitation for one of three sampled residents approved for compassionate care visits. (Resident 1) Findings include: Review of the facility policy entitled, Visitation Policy for Nursing Care Center Residents in Pennsylvania, dated September 21, 2020, revealed that compassionate care visitation was allowed in limited situations such as a resident having two or more documented significant changes in their condition. The resident's care plan was to reflect the compassionate care visits and the resident was not limited to a certain number of compassionate caregivers or number of days per week visits occur. If the facility suspended visitation, compassionate caregivers were permitted to access the facility. Clinical record review revealed that Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's current plan of care revealed that he was at risk for altered psychosocial well being and had a significant change which allowed for compassionate care visits from his family. Review of facility documentation revealed that the resident was approved for compassionate care visits on February 19, 2021. Review of facility communication to residents' families/responsible parties dated March 30, 2021 and March 31, 2021, revealed that in person visitation was suspend due to a staff member testing positive for COVID-19 and that compassionate care visits would resume April 1, 2021. In an interview on April 2, 2021, at 11:30 a.m. the Nursing Home Administrator (NHA) stated that compassionate care visits for qualifying residents started in the facility in February 2021. On March 29, 2021, the facility was notified of a staff member who tested positive for COVID-19. At that time the facility suspended all in person visitation, including compassionate care visits. The facility did not resume compassionate care visits until April 1, 2021. The NHA confirmed the facility did not allow compassionate care visits per facility policy. 28 Pa. Code 201.29(j) Resident rights.

Based on clinical record review, review of facility policy, review of incident report documentation and staff interview, it was determined that the facility failed to adequately supervise one resident to prevent an elopement from the secured health care center without staff's knowledge for one of four sampled residents who were at risk for elopement. (Resident R39) Findings include: Review of the facility's policy entitled Resident Elopement and Prevention, dated August 1, 2015, revealed that the facility was to promote resident safety and prevent accidents and injuries to residents with wandering behavior. Elopement was defined as when a resident leaves the skilled nursing premises or a safe area without authorization or necessary supervision to do so. Clinical record review revealed that Resident R39 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an elopement risk assessment dated [DATE], revealed that the resident had a history of [REDACTED]. At this time, an elopement risk care plan and a physician's orders [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired, required supervision with ambulation both on and off of the unit, and exhibited wandering and other behaviors that put himself or others at a significant risk for injury. Review of nursing documentation revealed that the resident on several occasions exhibited wandering behaviors especially in the evening: Nursing documentation as follows; October 8, 2015, 3:07 a.m., resident was awake and wandering the unit. He was reported to be awake and wandering for hours. He remained awake and anxiously wandering. October 26, 2015, 12:39 a.m., resident wandering this evening. Resident walked down the hallway and seemed confused as to where his room was located. October 29, 2015, 3:54 a.m., at approximately 2:15 a.m., resident was wandering the unit with exit seeking behavior, going to the end of the hallways and pushing on doors. He was agitated when re-directed by staff. October 30, 2015, 2:44 a.m., resident was awake and wandering halls and attempting to exit the facility. Multiple attempts to re-direct were unsuccessful. November 9, 2015, 12:33 a.m., resident with wandering behaviors all over the unit tonight. November 12, 2015, 12:02 a.m., resident wandering up and down the hallways. November 23, 2015, 12:44 a.m., resident continued with wandering behaviors. At approximately 9:10 p.m., the resident was noted to not be in his room or on the nursing unit. Review of a facility submitted report revealed that an extended search was initiated for Resident R39 as he had not been located on the secured nursing unit. The resident was not found until 11:11 p.m., (three hours after he had been initially noted as missing from the unit). The resident was found sitting on the floor inside a large walk-in refrigerator that is located off of the secured nursing unit in a kitchen/pantry. The nursing assessment noted his left fifth digit to be swollen with a small amount of blood. The resident was transferred and admitted to the hospital. Review of the hospital records revealed that the resident was admitted to the hospital on November 23, 2015, and discharged on [DATE]. The resident was diagnosed with [REDACTED]. Further review of facility documentation revealed that Resident R39 had received a treatment from a nurse at 8:09 p.m., which was the last time he was noted on the nursing unit. The documentation revealed that the resident was able to ambulate independently through the South Wing doors off of the nursing unit and proceeded to enter the kitchen/pantry area. The resident proceeded to walk in to the refrigerator at 8:26 p.m., and he was not found by facility staff until 11:11 p.m., (two hours and 45 minutes later), inside of the refrigerator. (All of the information was confirmed by the facility's review of camera surveillance after the incident.) In an interview on December 7, 2015, at 11:55 a.m., the Director of Nursing confirmed that the resident was last seen on the nursing unit at 8:09 p.m., and that the resident had been able to walk down the hallway, off of the unit through the South Wing doors. She confirmed that the wander guard system failed to function at this time to alert staff that the resident had left the secured nursing unit. The facility failed to provide adequate supervision in order to prevent this resident who was identified at risk for elopement and had actively displayed exit-seeking behaviors from exiting the secured nursing unit without the knowledge of staff. 28 Pa. Code 211.12(d)(1)(5) Nursing services.