Every finding on record at Lutheran Community at Telford

Based on policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that a registered nurse (RN) maintained professional standards of quality in carrying out nursing care to promote and maintain the well-being of individuals as set forth in the Pennsylvania Code Title 49 Professional and Vocational standards for one of eleven sampled residents. (Resident 22)Findings include: Review of Pennsylvania Code Title 49, Chapter 21, State Board of Nursing, Subchapter A, Registered Nurses, revealed guidelines which included that an RN shall carry out actions which promote, maintain, and restore the well-being of individuals and follow appropriate standards of practice and professional codes of behavior to assure safe and effective practice. Review of the facility policy, titled Peripherally Inserted Central Catheter (PICC), last reviewed May 20, 2026, revealed that residents with PICC lines would have site care performed and the dressing changed one time per week and as needed for transparent clear dressings, and staff were to initial and date the new dressing at the time of dressing change. Clinical record review revealed that Resident 8 had diagnoses that included discitis (a painful inflammation and infection of the intervertebral disc space between the spinal bones) of the lumbar-sacral region of the spine and osteomyelitis (an infection of the bone). Resident 8 was readmitted to the facility on [DATE], after a hospitalization with a PICC line in place and orders for daily intravenous antibiotic treatments. On May 14, 2026, a physician ordered staff to give Resident 22 two grams of an antibiotic (cefepime hydrochloride) intravenously through the PICC line. On May 20, 2026, a physician ordered staff to change the PICC line dressing every Wednesday for infection prevention. Resident 22's task administration record for June, 2026, indicated that Registered Nurse (RN) 1 changed the PICC line dressing on the morning of Wednesday, June 17, 2026. Observations of Resident 8 on June 16, 2026, at 11:27 a.m., and 1:35 p.m., and on June 17, 2026, at 12:38 p.m., revealed that a PICC line was in place to the right upper arm and covered with a transparent dressing. No date or initials were observed on the dressing. In an interview on June 17, 2026, at 2:08 p.m., the Director of Nursing confirmed that the dressing should have been initialed and dated per the policy. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, review of facility documentation, clinical record review, and staff interview, it was determined that the facility failed to implement safety precautions and develop interventions to prevent further falls for one of two sampled residents at risk for falls. (Resident 9) Findings include: Review of the facility policy entitled, Accidents and Incidents, last reviewed May 20, 2026, revealed that after a fall, vital signs were to be taken and recorded initially and every shift for 24 hours, the interdisciplinary team was to determine final interventions, and the care plan was to be updated. Clinical record review revealed that Resident 9 had diagnoses that included dorsalgia (back pain from muscles, nerves, or joints), dementia, history of falls, and restlessness and agitation. The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired and dependent on staff for activities of daily living. A review of facility documentation dated June 7, 2026, indicated that the resident had an unwitnessed fall in her room. After the fall, there was lack of evidence that staff continued to obtain vital signs every shift for 24 hours, as per facility policy. There was a lack of evidence that the interdisciplinary team had discussed and determined new interventions or that any additional measures were implemented following the fall to prevent a reoccurrence. A review of Resident 9's care plan revealed that the resident was at risk for falls and had previous falls, but did not indicate that an intervention was implemented after the resident's fall on June 7, 2026. In an interview on June 17, 2026, at 2:45 p.m., the Director of Nursing confirmed that there was no documented evidence that vital signs were obtained per policy and that the interdisciplinary team had discussed and developed interventions to prevent further falls, and that these things should have been done after Resident 9's fall on June 7, 2026. CFR 483.25(d)(1)(2) Accidents.Previously cited 11/21/2025 28 Pa. Code 211.10(d) Resident care policies. 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 a resident with pressure ulcers received necessary treatment and services for one of two sampled residents with wounds. (Resident 22)Findings include: Review of the facility policy entitled, Wound Care, last reviewed May 20, 2026, revealed that staff were to utilize preventative measures to avoid the development of pressure injuries unless the development was clinically unavoidable and necessary treatments and services were to be provided to promote healing and prevent infection and new injuries from developing. Clinical record review revealed that Resident 22 had diagnoses that included Alzheimer's disease, malnutrition, and diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident 22 had severe cognitive impairment, was incontinent, was dependent on assistance from staff for incontinence care and activities of daily living, and was at risk for developing pressure ulcers or injuries. Review of the care plan revealed the resident was at risk for pressure ulcer development related to immobility, peripheral vascular disease, and incontinence, had actual skin breakdown including a stage three pressure ulcer, and included an intervention for a licensed nurse to perform weekly skin evaluations. On May 18, 2026, staff documented that a small open area was identified on Resident 22's coccyx (tailbone) and left lower buttocks with unhealed moisture associated skin damage and an order was placed for wound care to evaluate Resident 22's wounds. Review of Resident 22's weekly skin assessments revealed no documented evidence the full body skin evaluation was completed on April 21, 2026, and May 21, 2026. In an interview on June 17, 2026, at 2:27 p.m., the Director of Nursing confirmed that staff did not perform the weekly skin inspections on Resident 22 on April 21, 2026, or May 21, 2026, and they should have. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident was free from safety hazards due to receiving the wrong medications for one of five sampled residents. (Resident 4)Findings include:Clinical record review revealed that Resident 4 had diagnoses of congestive heart failure, anxiety and atrial fibrillation. The Minimum Data Set assessment dated [DATE], indicated that the resident had some memory impairment. Review of an incident report dated November 13, 2025, at 5:20 p.m., revealed that an agency nurse RN1 gave Resident 4 another resident's (Resident 5) evening medications. In an interview on November 21, 2025, at 10:14 a.m., the Director of Nursing stated that the procedure for staff to identify a resident during medication pass was to check the picture in the electronic medication administration record and compare it to the resident being given the medications. At this time, the Director of Nursing confirmed that RN1 did not correctly identify Resident 4 through the electronic medication administration record to ensure that she was giving medications to the correct resident. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on facility policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure that adequate catheter care was provided for one of two sampled residents with an indwelling urinary catheter. (Resident 15) Findings included: Review of the facility policy entitled, Foley Catheter, Maintenance, last reviewed June 2, 2025, revealed that catheter maintenance was completed with current standards of care which included not to place the catheter bag on the floor. Clinical record review revealed that Resident 15 had diagnoses that included neuromuscular dysfunction of the bladder and congestive heart failure. On April 12, 2025, the physician ordered for the resident to have an indwelling catheter every shift. On July 1, 2025, at 10:39 a.m. and 1:28 p.m., Resident 15 was observed lying in bed with the catheter bag containing urine on the floor and the overbed tray table wheels on top of the bag. On July 2, 2025, at 12:35 p.m., Resident 15 was observed sitting in a reclining chair with the catheter bag containing urine on the floor. In an interview on July 2, 2025, at 1:20 p.m., the Director of Nursing confirmed that the indwelling catheter bag should not be in contact with the floor. CFR 483.25(e) Incontinence Previously cited 5/13/25 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident was provided individualized care and services in regard to diagnostic testing and was not catheterized unless necessary for one of four sampled residents. (Resident 1) Findings include: Review of the facility policy entitled, Bladder Care/Foley Catheter Insertion, Removal/Obtaining Specimen, revealed that foley catheter insertion, maintenance, and removal were to be completed in accordance with current standards of care. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included heart failure, anemia, malignant neoplasm of the prostate, and acute kidney failure. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident was alert and oriented and was continent of bladder. A review of the care plan dated April 2, 2025, revealed that he was at risk for incontinence due to impaired mobility and that he was continent of bladder. There was an intervention to assist the resident to the toilet as needed and to ensure that he had an unobstructed path to the bathroom. Further review of nursing documentation dated April 4, 2025, revealed that the resident was alert and oriented and was able to independently ambulate to and from the bathroom. A review of the care plan dated April 7, 2025, revealed that Resident 1 had a fever of unknown origin. There was an intervention for staff to obtain a urine specimen for analysis to rule out a UTI. On April 7, 2025, a physician ordered for staff to obtain a urine specimen for analysis due to fever. On April 8, 2025, at 5:54 a.m., a registered nurse noted that the resident had been straight catheterized for the urine specimen. The nurse further noted that the urine was yellow with some sediment noted and that his bladder had emptied for almost 500 cubic centimeters (cc) of yellow urine. The nurse also noted that at the end of the output the resident had hematuria (blood in the urine). At 4:15 a.m., the resident rang the call bell because he had taken himself to the bathroom and staff had noted hematuria in the toilet. In an interview on May 13, 2025, at 12:30 p.m., the Director of Nursing stated that the nurse had collected the urine specimen via catheterization as per the policy; however, the resident was alert and oriented, able to make his needs known to staff, able to urinate on his own, and able to take himself to the bathroom. The facility failed to ensure the resident was not catheterized unless necessary and failed to provide individualized care and services in order to obtain a urine specimen by means other then catheterization when the resident was able to voluntarily void. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 19 sampled residents. (Resident 19) Findings include: Clinical record review revealed that Resident 19 had diagnoses that included hypotension and Parkinson's disease. A physician's order dated May 5, 2023, directed staff to administer a medication (midodrine hydrochloride) three times a day for orthostatic hypotension (low blood pressure when standing, sitting, or lying down). Staff was not to administer the medication if the resident's systolic blood pressure (SBP) was 140 millimeters mercury (mm/Hg) or higher. Review of Resident 19's Medication Administration Record revealed that staff administered the medication when the resident's SBP was above 140 mm/Hg on four occasions in May 2024 and one occasion in June 2024. In an interview on June 13, 2024, at 12:10 p.m., the Director of Nursing confirmed that the medications were administered outside of established parameters for Resident 19. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's current status for one of 17 sampled residents. (Resident 15) Findings include: Clinical record review revealed that Resident 15 was readmitted to the facility on [DATE], and had diagnoses that included anemia, peripheral vascular disease, diabetes mellitus, arthritis, and dementia. Review of a nursing admission assessment dated [DATE], revealed no documentation that Resident 15 had a pressure ulcer. On May 17, 2023, a nurse noted that staff identified a suspected deep tissue injury to the right heel. Review of section M (assessment that determined the condition of the resident's skin) of the MDS assessment dated [DATE], indicated that the resident had an unhealed pressure ulcer that was present upon admission to the facility. In an interview on July 7, 2023, at 9:40 a.m., Registered Nurse 1 confirmed that Resident 15 had a pressure ulcer to the right heel and that the ulcer developed after the resident was readmitted to the facility.

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to maintain a medication error rate of less than five percent on one of two nursing units observed during medication administration. (Second floor nursing unit) Findings include: Clinical record review revealed that Resident 7 had a physician's order dated June 7, 2023, that staff was to administer divalproex (an anticonvulsant medication) every morning. The order indicated that the medication was to be given whole and was not to be crushed. Clinical record review revealed that Resident 47 had a physician's order dated June 28, 2022, that staff was to administer aspirin every morning. The order indicated that the medication was to be given whole and was not to be crushed. During observation of medication administration on July 6, 2023, at 8:49 a.m., Licensed Practical Nurse (LPN1) crushed both medications which resulted in a medication error rate of 5.41%. In an interview on July 7, 2023, at 1:29 p.m., Registered Nurse 1 confirmed that the medications were not to be crushed. 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 provide appropriate treatment and services in order to restore urinary continence to the extent possible for one of one sampled resident who had urinary incontinence. (Resident 53) Findings include: Review of the facility policy entitled Bladder Training, dated May 11, 2022, revelaed that bladder training was to be initiated after an evaluation of a resident on admission or who developed increased incontinency and it was determined that the continence could possibly be restored. The objective was to restore the resident to his/her fullest capability. The facility was to identify a voiding pattern to be determined by caretracker documentation. If the resident was a candidate for bladder re-training, it was to be discussed with the resident and documented on nurse's notes for agreement or refusal. Clinical record review revealed that Resident 53 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], indicated that the resident had some memory impairment, required limited assistance with toilet use, was occasionally incontinent of urine and was not on a toileting program. On August 4, 2022, a nurse noted that the resident continued to be forgetful but was able to make his needs known. Review of bladder incontinence documentation revealed that the resident was incontinent of urine at least 24 times in the last 30 days. There was no documented evidence that the facility had evaluated or assessed the resident's urinary incontinence. There was no documented evidence that the facility completed a voiding pattern to determine if the resident was a candidate for bladder re-training. In an interview on August 25, 2022, at 10:10 a.m., the Director of Nursing stated that the facility had not assessed the resident's urinary incontinence nor provided treatment and services in order to restore bladder continence as per facility policy. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a PRN (as needed) psychoactive medication was limited to 14 days unless the physician documented in the clinical record the rationale for the PRN to be extended beyond 14 days for one of five sampled residents on as needed psychoactive medication. (Resident 14). The facility also failed to document attempts to offer non-pharmacological interventions prior to the administration of PRN anti-anxiety medication for one of five sampled residents on as needed psychoactive medication. (Resident 28). Findings include: Clinical record review revealed that Resident 14 had diagnoses that included dementia and anxiety and had a current physician's order for staff to administer a psychoactive medication ([MEDICATION(S)]) every four hours as needed for anxiety since April 29, 2022. The current order for the [MEDICATION(S)] failed to include a time frame for the continued use of the medication. There was no physician documentation that it was appropriate for the order to be extended beyond 14 days. In an interview on August 25, 2022, at 9:22 a.m., the Director of Nursing stated that [MEDICATION(S)] orders for Resident 14 should have been stopped after 14 days or re-evaluated by the physician. Clinical record review revealed that Resident 28 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's, anxiety, and depression. The Minimum Data Set assessment dated [DATE] , 2022, indicated that the resident was cognitively impaired. Review of the current care plan revealed that Resident 28 exhibited aggressive behaviors with an intervention to anticipate and meet the needs of the resident. On June 10, 2022, the physician ordered an anti-anxiety medication, [MEDICATION(S)], be given every eight hours as needed. Review of the medication administration records (MAR) for June 2022, revealed that staff had administered as needed [MEDICATION(S)] 23 times. Review of the MAR for July 2022, revealed that staff administered [MEDICATION(S)] 26 times. Review of the MAR for August 2022, revealed that the medication was administered 20 times. There was no documented evidence to support that staff attempted non-pharmacological interventions prior to the administration of the as needed anti-anxiety medication. In an interview on August 25, 2022, at 09:20 a.m., the Director of Nursing confirmed that there was no documented evidence that staff attempted non-pharmacological interventions prior to the administration of the as needed anti-anxiety medication. 28 Pa. code 211.12(d)(5) Nursing Services.

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate injuries of unknown origin to rule out abuse or neglect for one of 20 sampled residents. (Resident 18) Findings include: Review of the facility policy entitled, Accident and Incident Policy, dated October 28, 2020, revealed that staff was to report all instances of bruising including injuries of unknown origin and that the facility was to conduct a thorough investigation. Clinical record review revealed that Resident 18 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On June 8, 2021, staff noted on the resident's weekly skin assessment that they identified a new bruise on the resident's shoulder. There was no documented evidence that staff reported the bruise to the facility, or that the facility investigated the cause of the bruise. In an interview on September 1, 2021, at 2:11 p.m., the Director of Nursing confirmed that Resident 18's bruise of unknown origin was not reported to the facility or investigated. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on clinical record review and staff interview, it was determined that the facility failed to specify a physician's order duration or attempt non-pharmacological interventions prior to administration of psychoactive medication prescribed on an as needed basis for three of 18 sampled residents. (Residents 4, 34, 41) Findings include: Clinical record review revealed that Resident 4 had [DIAGNOSES REDACTED]. The current care plan identified that the resident displayed a mood disorder with compulsive behaviors. A physician's order dated August 3, 2020, directed staff to administer an anti-anxiety medication ([MEDICATION NAME] every six hours) on an as needed basis for chronic anxiety/restlessness. The physician's order did not specify a date to discontinue the medication. Clinical record review revealed that Resident 34 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident displayed verbal behavioral symptoms one to three times per week. The current care plan identified that the resident displayed periods of increased agitation and verbal episodes. Physician's orders dated August 14, 2020, and September 4, 2020, directed staff to administer an anti-anxiety medication ([MEDICATION NAME]) on an as needed basis for anxiety. Review of the Medication Administration Record [REDACTED]. There was no documented evidence that staff offered non-pharmacological interventions prior to the administration of the as needed psychoactive medication on three of four occasions. Clinical record review revealed that Resident 41 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident displayed verbal behavioral symptoms one to three times per week, feelings of depression, and refusing care. The current care plan identified that the resident displayed mood fluctuations, including increased frustration and anxiety. Physician's orders directed staff to administer an anti-anxiety medication, [MEDICATION NAME], on an as needed basis for anxiety. Review of the Medication Administration Record [REDACTED]. There was no documented evidence that staff offered non-pharmacological interventions prior to the administration of the as needed psychoactive medication. During an interview conducted on September 24, 2020, RN1 stated that nonpharmacological intervention documentation for psychoactive medications prescribed on an as needed basis was to be entered in the progress notes section of the clinical record. 28 Pa. Code 211.12(d)(1)(5)Nursing services.

Based on observations, staff interviews and review of manufacturers' instructions, it was determined that the facility failed to properly maintain labeling of medication storage and clean medication carts in two of three areas. Findings include: Observation of the 2nd floor medication cart on September 23, 2020, at 9:00 a.m., revealed that a dry liquid substance was noted throughout the bottom drawer and on the side of the cart. Observation of the 2nd floor medication refrigerator on September 23, 2020, at 9:15 a.m., revealed open medication vials of [MEDICATION NAME], Med Pass 2.0 and Thickened Lemon-Flavored Water with no identified open date on the medications and liquids. Observation of the 3rd floor medication cart on September 23, 2020, at 10:30 a.m., revealed a dry liquid substance throughout the bottom drawer. Observation of the 3rd floor medication refrigerator on September 23, 2020, at 10:45 a.m., revealed upon open medication vials of [MEDICATION NAME], Med Pass 2.0, and thickened cranberry juice with no identified open dates on medication or liquids. In an interview on September 23, 2020, at 11:00 a.m., the Director of Nursing stated hat the facility had no procedures in place to clean medication carts or inspect medication storage areas for open dates for medication and liquids. 28 Pa.Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on policy review, clinical record review and staff interview, it was determined that the facility failed to thoroughly investigate accidents and incidents to determine if assessed safety measures were implemented and revised as needed for one of 18 sampled residents. (Resident 46) Findings Include: Review of the facility policy entitled, Accident and Incident Policy dated July 1, 2020, revealed that staff is to complete nurses' notes and incident reports using all information collected regarding the circumstances surrounding the incident to reduce further incidents. Clinical record review revealed that Resident 46 had a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], identified that the resident was cognitively impaired and required extensive assistance for activities of daily living. The current care plan identified that the resident was at risk for falls with injuries and directed staff to implement safety interventions. Review of the clinical record and facility documentation revealed that from December 12, 2019, to January 18, 2020, the resident had a history of [REDACTED]. Although, no further falls were identified, the resident sustained [REDACTED]. There was no documentation to support that the facility had reviewed or implemented additional interventions to determine causes of the ongoing left knee injuries to prevent further accidents and/or incidents. CFR 483.25(d)(1)(2) Accidents Hazards/Supervision Devices Previously cited 4/26/2019. 28 Pa. Code 211.10(d) Resident care policies. 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 thoroughly investigate falls to determine if assessed safety measures were implemented and functional and that the Interdisciplinary Team (IDT) had been involved in the investigative process for three of nine sampled residents who had fallen. (Resident 30, 35, 42) Findings include: Review of the facility policy entitled Accident and Incident Policy dated (MONTH) 30, (YEAR), revealed that the interdisciplinary team was to work with the resident to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing independence. Clinical record review revealed that Resident 30 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated (MONTH) 6, 2019, identified that the resident had cognitive impairment, required staff assistance for activities of daily living and had falls during the assessment period. The ongoing care plan dated (MONTH) 10, (YEAR), identified the resident a high risk for falls and directed staff to implement a bed alarm safety device, offer a toileting plan for bathroom privileges, seating and positioning, an activity when in the lounge, frequent checks during morning naps and do not lock the wheel chair brakes to prevent mobility unless transferring. Review of the clinical record and other facility documentation revealed that from (MONTH) 16, (YEAR) to (MONTH) 11, 2019, the resident had eleven falls. Review of the fall on (MONTH) 16, (YEAR) at 7:15 a.m., revealed that the resident was found on the floor after she had attempted toileting. There was no documentation to support that the facility had offered a toileting plan as indicated. Review of the falls on (MONTH) 16, (YEAR) at 6:45 p.m., (MONTH) 25, (YEAR) and (MONTH) 22, (YEAR), revealed that the resident was found on the floor after leaning and positioning. The resident notified the facility of that concern to the facility but there was no documentation to support that seating and positioning had been addressed. Review of the fall on (MONTH) 8, (YEAR), revealed that the resident fell forward out of the wheelchair after the brakes had been locked and limited her mobility. Review of two falls on (MONTH) 20, (YEAR), revealed that the resident was found on the floor in the lounge but there was no clinical documentation to support that activities had been offered as indicated by the IDT. Review of three falls on (MONTH) 27, (YEAR), (MONTH) 3, 2019 and (MONTH) 8, 2019, revealed that frequent checks as recommended by psychological services during morning naps had not been done as indicated. Lastly, review of the fall on (MONTH) 11, 2019, revealed that the resident's bed alarm had not functioned to alert staff after the resident had fallen out of bed. Clinical record review revealed that Resident 35 had [DIAGNOSES REDACTED]. The MDS assessment dated (MONTH) 12, 2019, identified that the resident had memory and decision making impairment, required staff assistance for activities of daily living and had falls during the assessment period. The ongoing care plan most recently reviewed on (MONTH) 14, 2019, identified the resident at risk for falls and directed staff to implement safety interventions such as call bell in reach and supervision. Review of the clinical record and other facility documentation revealed that from (MONTH) 18, (YEAR) to (MONTH) 16, 2019, the resident had four falls. Review of the falls on (MONTH) 29, 2019 and (MONTH) 16, 2019, revealed that the resident was found sitting on the floor in her room but the facility had no investigation that identified that the resident had been supervised by staff. Review of the falls on (MONTH) 18, (YEAR) and (MONTH) 13, 2019, revealed that the resident's call bell had not been accessible. Clinical record revealed that Resident 42 had [DIAGNOSES REDACTED]. The MDS assessment dated (MONTH) 20, 2019, identified that the resident was cognitively and visually impaired, required staff assistance for activities of daily living and had falls during the assessment period. The care plan most recently reviewed (MONTH) 26, 2019, identified the resident was a high risk for falls and directed staff to implement safety interventions such as frequent checks, repositioning and staff supervision. Review of the clinical record and other facility documentation revealed that from (MONTH) 2, (YEAR) to (MONTH) 23, 2019, the resident had eleven falls. Review of the falls on (MONTH) 2, (YEAR), (MONTH) 10, (YEAR), (MONTH) 15, (YEAR), (MONTH) 25, (YEAR), (MONTH) 29, (YEAR), (MONTH) 4, (YEAR), (MONTH) 9, (YEAR), (MONTH) 20, 2019, (MONTH) 20, 2019, and (MONTH) 23, 2019, revealed that the resident was found on the floor but the facility had no investigation that identified that the resident had been supervised by staff, frequently checked or repositioned. There was no clinical documentation to support that the IDT investigative process reviewed ongoing preventative interventions for efficacy. In an interview on (MONTH) 26, 2019 at 9:30 a.m., the Director of Nursing confirmed that there was no documented evidence these interventions were implemented. CFR 483.25(d)(1)(2) Accidents Hazards/Supervision/Devices Previously cited 5/18/18 28a. Pa Code 211.12(d)(1)(3) Nursing services Previously cited 5/18/18

Based on clinical record review, staff interview and review of facility policy, it was determined that the facility failed to thoroughly investigate falls to determine if assessed safety measures were implemented and functional and that the interdisciplinary team had been involved in the investigative process for two of two sampled residents who had a history of [REDACTED]. Findings include: Review of the facility policy entitled Accident and Incident Reporting and Fall Risk assessment dated (MONTH) 9, (YEAR), revealed that the interdisciplinary team was to work with the resident to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing independence. Clinical record review revealed that Resident 12 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated (MONTH) 26, (YEAR), identified that the resident had severe memory impairment, required limited assistance from staff for mobility and had falls during the assessment period. The ongoing care plan initiated on (MONTH) 6, (YEAR), identified the resident at risk for falls and directed staff to anticipate the resident's needs, ensure the bed was in the low position, have the call bell in reach and remind the resident to use her walker. Review of the clinical record and other facility documentation revealed that from (MONTH) 4, (YEAR), to (MONTH) 2, (YEAR), the resident had five falls. Review of the fall on (MONTH) 4 and 16, (YEAR), revealed that the resident was found sitting on the floor in her room, but the facility had no investigation that identified whether the resident's bed was in the low position. Review of the fall on (MONTH) 1, (YEAR), revealed that the resident was found sitting on the floor in her room but the facility investigation failed to that reflect whether the resident's bed was in the low position or if the resident had her walker accessible and call bell within reach. The care plan was revised (MONTH) 1, (YEAR), and continued to identify the resident at risk for falls and directed staff to provide increased visualization. Review of the fall on (MONTH) 1, (YEAR), revealed that the resident was found sitting on the floor in her room. There was no documentation to support that staff facility had the resident's bed in the low position, the call bell was within reach or if they had attempted increased visualization. Review of the fall on (MONTH) 2, (YEAR), revealed the resident was found on the dining room floor without her walker. There was also no evidence to support that staff had attempted increased visualization. Clinical record review revealed that Resident 33 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated (MONTH) 16, (YEAR), identified that the resident had severe memory impairment, required extensive assistance with mobility and had falls during the assessment period. The ongoing care plan initiated (MONTH) 26, (YEAR), identified the resident at high risk for falls and directed staff to anticipate needs, provide close supervision, ensure bolstered bed was in the low position with a mat placed bedside on the floor, implement safety devices such as bed and chair alarm and provide quick response to the sounding alarms. Review of the clinical record and other facility documentation revealed that from (MONTH) 27, (YEAR), to (MONTH) 17, (YEAR), the resident had thirteen falls. Review of the fall on (MONTH) 27, (YEAR), revealed that the resident was found sitting on the floor in her room but the facility had no investigation that identified whether the safety concave mattress was in place at the time of the fall. Review of the falls (MONTH) 6 and 8, (YEAR), and two falls on (MONTH) 28, (YEAR), revealed that the facility had not investigated these incidents to determine whether mechanical devices were in use at the time of these falls. Review of the falls on (MONTH) 8, (YEAR) and (MONTH) 11, (YEAR), revealed that the resident fell from her bed but the investigation failed to identify if a floor mat was in place. Review of the falls (MONTH) 2, 18,19, 24, (YEAR), and (MONTH) 6, 17, (YEAR), revealed devices in place but did not include whether the device was responded to timely, monitored, or effective in fall prevention. In an interview on (MONTH) 18, (YEAR), at 9:30 a.m., the Director of Nursing confirmed that the facility did not evaluate the effectiveness of fall interventions and had no further investigative documentation into the circumstances of the resident's falls. 28 Pa. Code 211.12(d)(1)(3) Nursing services Previously cited 4/28/17

Based on clinical record review and staff interview, it was determined that the facility failed to implement care planned interventions for one of 17 sampled residents. (Resident 59) Findings include: Clinical record review revealed that Resident 59 had [DIAGNOSES REDACTED]. On (MONTH) 13, 2108, clinical documentation revealed that the resident had both casts removed by an orthopedic physician. Review of the current care plan revealed the resident was at high risk for pressure ulcer and skin impairment related to surgical sites. The care plan directed staff to follow facility protocols for treatment when pressure ulcers were identified, to include a pressure ulcer risk assessment within 48 hours by the resident care coordinator and then weekly assessments times three on bath days. It further required nursing staff to do weekly skin inspections and monitor or document location, size, and treatment of [REDACTED]. In an interview on (MONTH) 17, (YEAR), at 8:45 a.m. the Director of Nursing confirmed that the pressure ulcer and skin assessment interventions were not implemented. 28 Pa. code 211.12(d)(1)(5) Nursing services Previously cited 4/28/17

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that an antianxiety medication was necessary and not excessive in dose for one of six sampled residents that received antianxiety medications. (Resident R12) Findings include: Clinical record review revealed that Resident R12 had [DIAGNOSES REDACTED]. On August 28, 2016, the physician ordered [MEDICATION NAME] (an antianxiety medication) by mouth twice daily (2:00 p.m. and 6:00 p.m.) and to use [MEDICATION NAME] gel (a topical form of the antianxiety medication) when nursing staff were unable to give the scheduled dose orally. Review of the Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. In an interview on April 27, 2017, at 11:00 a.m., the Director of Nursing confirmed that there was no medical justification or indication for excessively administering the antianxiety medication. 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 thoroughly investigate falls and evaluate the effectiveness of an assessed safety devices to prevent falls for one of six sampled residents who had a history of [REDACTED]. (Resident R65) Findings include: Clinical record review revealed that Resident R12 had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE], identified that the resident had memory and decision making impairment, required extensive assistance with mobility and had falls during the assessment period. The ongoing care plan most recently reviewed on February 17, 2017, continued to identify the resident at risk for falls and directed staff to provide close supervision, implement safety devices such as bed and chair alarms and provide quick response to the sounding alarms. Review of the clinical record and other facility documentation revealed that from January 18, 2017, to April 24, 2017, the resident had nine falls. Review of the falls on January 18 and 25, 2017, February 27, 2017, and April 24, 2017, revealed that the facility had not investigated these incidents at all. Review of the fall on January 20, 2017, revealed that the resident was found sitting on the floor in her room but the facility had no investigation that identified whether the assessed safety device was in place and functioning at the time of the fall. Review of the remaining falls on January 20 and 23, 2017, April 6 and 10, 2017, revealed an alarming device had been in place but did not include whether the device was responded to timely, monitored, or effective in fall prevention. In an interview on April 26, 2017, at 10:50 a.m., the Director of Nursing confirmed that the facility did not evaluate the effectiveness of fall interventions and had no further investigative documentation into the circumstances of the resident's falls. Clinical record review revealed that Resident R65 had [DIAGNOSES REDACTED]. Since admission to the facility on [DATE], the resident has had multiple falls that included a fall from bed. A MDS assessment dated [DATE], identified that the resident had short term memory impairment, was dependent on staff to make daily decisions, and needed staff assistance to transfer between surfaces and to walk. The quarterly bed side rail assessments from June 10, 2016, identified that the resident had balance problems, cognitive decline and a history of falls. The assessments concluded that the resident was to have a one half side rail positioned in the up position for bed mobility when staff was caring for the resident. The assessment indicated that staff was to release the side rail after staff provided care to the resident. Resident R65's current care plan and physician's orders [REDACTED]. The resident was observed in bed April 25, 2017, at 1:28 p.m., and 2:34 p.m., and again on April 26, 2017, at 8:30 a.m., 8:45 a.m., and 9:10 a.m. The resident was unsupervised at these times and the siderails were positioned in the up position. Staff failed to utilize the bed siderails as assessed to ensure that the resident's environment was free of accident hazards as possible. In an interview on April 28, 2017, the Director of Nursing stated that Resident's R65's bed siderail should be in the up position when staff was caring for the resident and should be placed in the down position once care had been provided. 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 5/9/16 28 Pa. Code 211.12(d)(3) Nursing services